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department  of  burger? 
?lluU  jWemorial  Jf  unb 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 
Columbia  University  Libraries 


http://www.archive.org/details/operativesurgery02brya 


OPERATIVE   SURGERY 


JOSEPH    D.   BRYANT.   M.  D. 

Professor  of  the  Principles  and  Practice  of  Surgery,  Operative  and  Clinical  Surgery, 
University  and  Bellevue  Hospital  Medical  College  ;  Visiting  Surgeon  to  Hellevue 
and  St.  \'incent's  Hospitals;  Consulting  Surgeon  to  the  Hospital  for  Rup- 
tured and  Crippled,  Woman's  Hospital,  and  Manhattan  State  Hospital 
for    the    Insane ;    Fellow   of   the   American    Surgical    Association ; 
former    President    of  the    New  York  Academy  of    Medicine; 
President  of  the  New  York  State  Medical  Association,  etc. 


Vol.  II 

OPERATIONS    ON    MOUTH,    NOSE,    AND    OESOPHAGUS, 

THE  VISCERA   CONNECTED  WITH    THE    PERITON.'EUM, 

THE     THORAX     AND     NECK,     SCROTUM     AND     PENIS, 

AND   MISCELLANEOUS   OPERATIONS 


THIS    VOLUME  CONTAINS 

EIGHT  HUNDRED  AND    TWENTY-SEVEN  ILLUSTRATIONS 

FORTY  OF    WHICH  ARE    COLORED 


NEW     YORK 

D.     APPLETON     AND     COMPANY 

1901 


Copyright,  1886,  1899,   1901, 
By  D.   APPLETON   AND    COMPANY. 

All  riffhts  reserved. 


CONTENTS   OF  VOLUME   11. 


CHAPTER   XIII. 

OPERATIONS    ON    MOL'TH,    PHARYNX.    NOSE,    AND    (ESOPHAfiL'S. 

PAOE 

Salivarv  fistvila — Ajjiiew's  method  of  cure — Dessaulfs  metliod — Van  Buren's  method 
— Richi'lot's  method — Dequise's  method — Excision  of  tonsil — Removal  with  knife 
or  scissors — Abscess  of  tonsil — Operations  on  tongue — Langenbeck's  method — 
Preliminary  laryngotoniy — Excision  of  tongue — V-shaped  incision — Ilyper- 
tropiiy  of  tongue —  Removal  of  entire  tongue — Removal  of  half  of  tongue — Opera- 
tion through  mouth — Whitehead's  method — Kocher's  method — Removal  of 
tongue  with  division  of  jaw — Jaeger's  method — Baker's  method — Rignoli's 
method — Billroth's  method — Choice  of  method — The  results — Tongue-tie — Ran- 
ula — Removal  of  tumor  of  tonsil  and  pillar  of  fauces — Pharyngotomy — Cheever's 
method — Czerny's  method — ^Mikulicz's  method — General  remarks — The  results 
— Operations  on  nose — Plugging  of  posterior  nares — Removal  of  nasal  polypi — 
Removal  of  some  nasal  and  naso-pharyngeal  polypi — Nasal  route — Chassaig- 
nac's  method — OUier's  method — Lawrence's  method — Rouge's  method — Lan- 
genbeck's method — Palatine  route — Xelaton's  method — Chalot's  method — An- 
nandale's  method — IMaxillary  route — Boeckel's  method — Guerin's  method — 
Kocher's  method — Cheever's  method — General  comments — Choice  of  operation 
— The  results — Deviation  of  septum  nasi — Operations  for — Operations  on  cesoph- 
agus — Tlie  anatomical  points — Foreign  bodies  in  oesophagus — The  remarks — 
Introduction  into  oesophagus  of  instruments — A  method  of  introduction  of 
stomach  tube — Other  methods  of  introduction — The  precautions — The  remarks 
—Ingenious  plans  of  action  for  removal  of  special  obstructions — CEsophagotomy 
— Cervical  tesophagotomy — The  fallacies — The  remarks — The  after-treatment — 
The  results — Foreign  bodies  in  thoracic  oesophagus — Operations  on  oesophagus 
— Gastrotomy — The  operation — The  precautions — The  comments — Stricture  of 
oesophagus — Treatment  of — By  dilatation — By  retrograde  dilatation — By  divul- 
sion — By  direct  and  retrograde  divulsion — Internal  a^sophagotomy — Division 
by  string  friction — The  comments — Tubage — The  results — Esophagectomy — 
The  results — CEsophagotomy 563 

CHAPTER   XIV. 

OPERATIONS   ON    ^^SOERA    CONNECTED   WITH    PERIT0N.T:rM. 

Abdominal  section — Anatomical  points — Preparation  of  patient — The  operation — 
The  precautions — The  remarks — Cleansing  of  peritoneal  cavity — Drainage  of 
peritoneal  cavity — The  remarks — The  precautions — Closure  of  wound — The  com- 
ments— The  precautions — Treatment  of  wound — The  after-treatment — General 
comments — The  fallacies — Explorative  abdominal  section — Operations  on  in- 
testines— Indications   for — Intestinal   sutures — The  continuous  suture — Gely's 

iii 


iy  OPERATIVE  SURGERY. 

PAGK 

suture — Cushing's  suture — Lembert's  suture — Czerny-Lembort  suture — Wolf- 
ler's  sutui'e — Gussenbauer's  suture — Ilalsted's  suture — Jobert's  suture — Semi's 
modification  of  Jobert's  suture — Maunsell's  method  of  suture — Pylorectomy, 
Maunsell's  method — Gastro-enterostomy — Maunsell's  method — Murphy's  button 
— Lateral  aj)proximation — The  precautions — Tlie  comments — Laplace  intestinal 
approximation — End-to-end  approximation — The  comments — Lateral  approxi- 
mation— Bone  bobbins — Potato  bobbin — Robson's  bone  bobbin — Allingham's 
bone  bobbin — Hayes's  bone  bobbin — Neuber's  decalcified  bone  bobbin — Lidia- 
rubber  tube  bobbin  of  Robinson — End-to-end  approximation  of  unequal  seg- 
ments— Lateral  anastornosis — Senn's  method — Stamm's  method — Dawbarn's 
method,  potato  plates — The  remarks — Robinson's  segmented  rubber-plate  meth- 
od— Lateral  anastomosis  by  sewing  only — Abbe's  method — Halsted's  method — 
Maunsell's  method — Lateral  anastomosis  by  enterotome — Grant's  enterotome — 
Lateral  implantation — Maunsell's  method — Abdominal  section  for  wounds  of 
abdominal  viscera — Abdominal  section  in  penetrating  gunshot  wounds — The 
abdominal  incision — Detection  and  arrest  of  hiemorrhage — Search  for  intestinal 
wounds — The  comments — Repair  of  intestinal  wounds — Thickness  of  the  mus- 
cular coat — Special  importance  of  intestinal  wounds — Aseptic  regime  in  intes- 
tinal repair — P^lbowing  in  intestinal  repair — Wounds  of  omentum  and  mesen- 
teric luumorrhage — Resection  of  small  intestine — Kocher's  method  of  resection 
— Methods  of  control  of  ends  of  intestine  in  sewing — Halsted's  method  of  intes- 
tinal resection — Harris's  metliod  of  circular  enterorrhaphy — Treatment  of  the 
mesentery — The  precautions — The  results — Gunshot  wounds  of  duodenum — 
Gunsiiot  wounds  of  large  intestine — Stab  wounds  of  abdomen — The  comments 
— The  results — Contused  wounds  of  abdomen — The  results — Abdominal  section 
for  intestinal  obstruction — Enterostomy — Kocher's  method — The  precautions — 
The  remarks — The  I'esults — Artificial  anus — Enteroplasty — Omental  grafting — 
Colostomy — Iliac  colostomy — The  operation — The  remarks — The  precautions — 
Bodine's  operation — Cripps's  method — Landmann's  method — Reclus's  method — 
Colostomy,  right  iliac — Of  transverse  colon — Left  lumbar  colostomy — Linear 
guide  for  operation — Anatomical  points — The  fallacies — The  precautions — The 
I'esults — Right  lumbar  colostomy — Prognosis  in  intestinal  obstruction — Treat- 
ment in  urgent  cases — In  less  urgent  cases — Removal  of  cause  of  obstruction — 
Intussusception — Treatment  of — By  distention  with  air — Carbonic-acid  gas — 
Hydrogen  gas — With  fluid — The  remarks — The  results — Abdominal  section  in 
— Reduction  by  manipulation — By  lateral  anastomosis — By  artificial  anus — By 
enterorrhaphy — Maunsell's  method — Barker's  method — Paul's  method — Irre- 
ducible invaginations  of  small  intestine — Baracz's  method  of  treatment — Pro- 
lapsed invaginations — Mikulicz's  method  of  treatment — The  results — Coeliotomy 
for  acute  intussusception — Volvulus — The  remarks — The  results — Neoj)lasms — 
Diverticula,  etc. — Colectomy — The  operation — Paul's  method — Colon,  dilatation 
of,  idiopathic,  Treves's  case — Operations  on  transverse  colon — Resection  of  ileo- 
caecum — Removal  of  vermiform  appendix — Anatomical  points — Operative  tech- 
nique— The  incisions — The  remarks — The  treatment  of  appendix — Acute  appen- 
dicitis— The  remarks — The  results — Subacute  appendicitis — The  remarks — The 
results — Acute  appendicitis  with  perforation  and  circumscribed  sujjpuration — 
The  remarks — The  results — Recurrent  and  relapsing  appendicitis — The  remarks 
— The  results — The  gridiron  method — Acute  catarrhal  appendicitis  with  plastic 
exudation — The  remarks — The  results — Removal  of  appendix  during  interval — 
The  modified  incisions — Vischer's  incision — Meyer's  incision — Fowler's  incision 
— Weir's  incision — Stimson's  incision — McBurney's  method — Intestinal  perfora- 
tion in  typhoid  fever — The  operation — The  results — Peritonitis  in  perforation 
from  other  causes — The  results — Peritonitis  due  to  tuberculosis — The  results — 
Faecal  fistula  and  artificial  anus — Preparatory  treatment — The  operation — Greig 
Smith's  method  of  treatment — Instrumental  methods  of  treatment — The  results — 


CUNTKNTS.  y 

PAOB 

Operations  on  tlie  stomach — Anatomical  points — Preparatory  treatment — Gas- 
trotomy — Tlie  results — Clastrostomy — Stages  of  operation — Tlie  precautions — 
Tlie  results — Witzel's  method — Ssalmnejew-Franck  method — Ilahn's  modifica- 
tion of — Senn's  metiiod — Kader's  method — Stamm's  method — Andrew's  method 
— Marwedel's  method — Choice  of  openilion — (iastro-enterostomy — Anatomical 
points — Anterior  ami  jiosterior  gastro-eiit urostomy — Entero-anastomosis — Ante- 
rior {jastro-ent urostomy — Wuiller's  method — Lowenstein's  meliiod — .laboulay's 
method — W'iM tier's  later  method — Kocher's  method — Sonncnberg's  method — Pos- 
terior gast  re  )-e  lit  erostomy — \'on  I  lacker's  method — Konx's  method — Kntero-anas- 
tomosis  with  Murphy's  button — Gallet's  method  of — Results  of  gastro-enteros- 
toniy— Jejunostoniy — Maydl's  meliiod — Albert's  method — Pylorectomy — Pre- 
paratory treatment — Kocher's  method — Lines  of  section — Joininj^  intestine  to 
stomach — Pylorectomy  combined  with  gastro-entcrostomy — Kocher's  method — 
The  precautions — The  remarks — The  results — Pyloroplasty — Ileineke-.Miku- 
licz's  method — The  results — Divulsion  of  the  pylorus — The  i)recautions — The 
results — Dilatation  of  cardiac  orifice — Gastro-gastrostomy — Wolfler's  methoil — 
Watson's  method — The  results — Gastroplasty — Gastroplicalion — Bircher-Weir 
method — Moynihan's  modification — Brandt's  modification — Gastropexy  and 
gastrectomy — Partial  gastrectomy — Gastric  ulcer — Operation  for  perforated 
ulcer — Operation  for  non-perforating  ulcer — Operation  for  iKeniorrhage  from 
ulcer  of  the  stomach — Complete  gastrectomy — Schlatter's  case — Brigham's  case 
— Richardson's  case — Wounds  of  stomach — Operations  on  liver — Anatomical 
points — Abscess  of  liver — The  precautions — By  trocar  and  cannula — By  di- 
rect incision — General  comments — The  results — For  hydatids  of  liver — The 
results — Treatment  by  incision — Treatment  by  excision — Hepatectomy — Stages 
of — The  precautions  in — The  remarks — the  results — Wounds  of  liver — The 
results — Ilepatopexy — Ilepatotomy — Operation  for  cure  of  ascites  from  cir- 
rhosis of  liver — Operations  on  gallbladder — Anatomical  points — Cholecystotomy 
— The  operation — The  results — Cholecystendysis — The  results — Cholecystec- 
tomy— The  results — Choleeystenterostomy — With  JMurphy  button — By  sewing 
— The  results — Cholecysto-lithotrity — The  results — Cholelithotrity — Choledo- 
chotomy — Abdominal  route — Halsted's  method — Other  methods — The  jirecau- 
tions — Choledochotomy,  lumbar  route — Choledo-enterostomy — Assendri's  but- 
ton for — Boari's  button  for — Resection — Clioledochorrhaphy — Doyen's  method 
— Resection  of  border  of  thorax — Biliary  fistula — Operations  on  kidneys — Ana- 
tomical points — Nephropexy — The  operation — Senn's  method — Morris's  method 
— TautTer's  method — Bulliet's  method — Frank's  method — Exposure  of  kidney 
for  diagnostic  purposes — Linear  guides  for  operations  on  kidney — Anatomy  of 
incisions  in  operations  on  kidney — Results  in  nephropexy — Xephrolithotomy — 
Lumbar  method  of  operation — The  precautions — Morris's  method  of  explora- 
tion of  kidney — Abdominal  explorative  method  of  operation — Nephrotomy — 
The  precautions — The  results — Nephrectomy — Lumbar  nephrectomy — The  op- 
eration— Treatment  of  ureter — Treatment  of  pedicle — Abdominal  nephrectomy  . 
— Choice  of  operation — The  results — Partial  nephrectomy — Extra-peritoneal 
nephrectomy — Puncture  of  kidney — Wounds  of  kidney — Operative  treatment  of 
— Complications  in — The  results — O[)erations  on  ureters — Anatomical  points — 
Wounds  of  ureter — Treatment  of  —  Uretero-ureteral  anastomosis  —  TaufTer's 
method — Schopf-Cushing  method — Bovee's  method — Markoe's  method — Pog- 
gi's  method — Robson-Winslow  method — Van  Hook's  method — F^mmet's  meth- 
od— Kelly-Bloodgood  method — Implantation  of  ureter — Implantation  into 
bladder — Witzel's  method — Intraperitoneal  implantation — The  remarks — The 
results — Implantation  into  bowel — Cliaput's  method — Martin's  method — Fow- 
ler's method — Implantation  into  bladder — Implantation  on  skin — Into  vagina 
— Ureteral  calculus — Methods  of  treatment — The  results  of  treatment — Ure- 
terectomy— Varieties — Methods  of  treatment — Relief  of  valve  formation  of  ure- 


vi  OPERATIVE   SURGERY. 

PAGE 

ter — Kuster-Trendelenburg  method — Fenger's  method — Gerster's  method — 
Striclure  of  ureter — Alsberg's  method — Fenger's  method — Morris's  metliod — 
Resection  of  ureter  for  stricture — Kiister's  method — Morris's  method — Conchi- 
sions  of  Van  Hook — Conclusions  of  Fenger — Catheterism  of  ureter — Knee- 
breast  position  in — Elevated  dorsal  position  in — The  precautions — The  remarks 
— Differentiation  of  urines — Harris's  instrument  for — Brown's  instrument  for — 
Downes's  instrument  for — Operations  on  spleen — Anatomical  points — Splenec- 
tomy— The  precautions — Partial  resection — The  results — Splenoplexy — Hydy- 
gier's  method — Bardenhauer's  method — Zykow's  method — Aspiration  of  spleen — 
Splenotomy — Operations  on  pancreas — Anatomical  points — Operation  for  pan- 
creatic cyst — The  results — Subphrenic  abscess — Incisions  for  treatment  of — The 
results— Paracentesis  abdominis — The  precautions — Hernia  of  the  abdominal 
wall — Strangulated  hernia— Taxis — Herniotomy — Preparation  of  patient — Divi- 
sion of  tissues — Recognition  of  sac — Examination  of  contents — Division  of  stric- 
ture— Washing  out  stomach  in  faecal  vomiting — Strangulated  inguinal  hernia — 
The  results — Strangulated  femoral  hernia — The  results — Strangulated  umbili- 
cal hernia — The  results — Strangulated  obturator  hernia — The  results — Strangu- 
lated ventral  hernia — Retroperitoneal  hernije — The  results— Operations  for  the 
radical  cure  of  hernia — Inguinal  hernia — Bassini's  method — The  precautions — 
The  remarks — The  results  — Ilalsted's  method — The  remarks — The  results — 
Bloodgood's  modification  of  Ilalsted's  method — The  results — Lucas-Champion- 
niere's  method— The  results — Kocher's  method— The  results— MacEwen's 
method — The  results— The  various  modifications — General  precautions — Gen- 
eral results — Femoral  hernia — Radical  cure  of — Bassini's  method — The  results 
— Kocher's  method— Other  methods — Umbilical  hernia — Radical  cure  of — 
Greig  Smith's  method — Boeckel's  method — Dauriac's  method — The  results — 
Ventral  hernia — Radical  cure  of — Hernia  following  appendicitis — Lateral  ven- 
tral hernia — Caecal  hernia — Hernia  of  the  bladder — Local  anaesthesia  in  opera- 
tions on  hernia — Cushing's  method — The  remarks— The  results  ....     607 

CHAPTER   XV. 

OPERATIONS    ON   ANUS   AND   RECTUM. 

Examination  of  anus — Imperforate  anus — Absence  of  anus — Operation  for  relief  of 
— Fistula  in  ano — Examination  for  detection  of — Operative  treatment — Direct 
incision— Ligature  by  galvano-cautery— Horseshoe  form  of  fistula — Inconti- 
nence of  fieces — Treatment  of — Hasmorrhoids— Incision  method  of  treatment — 
Excision  methods  of  treatment — Allingham's  method— Whitehead's  method — 
Ligature  of  haemorrhoids — Subcutaneous  ligature — An  old  method  of  ligature 
— Coates's  method  of  treatment — The  ci-usliing  method  of  treatment — Clamp  and 
cautery  method— Injection  method— General  remarks— Choice  of  operation— 
The  results— Operations  on  rectum— Anatomical  points— Examination  of  rec- 
tum—Digital examination— Introduction  of  hand— Instrumental  examination 
— Ischio-rectal  abscess— Anatomical  points— Imperforate  rectum — Methods  of 
treatment— Proctoplasty— Rizzoli's  method  of  treatment— The  results— Prolap- 
sus recti— Methods  of  treatment— Treatment  of  complete  prolapsus— Treatment 
by  caustics  or  cautery— Lange's  method  of  treatment— Roberts's  method— 
Mikulicz's  method— Treves's  method— Kleberg's  method— Verneuil's  method— 
Tuttle's  method— Peter's  method— Colopexy—Jeannel's  method  of  treatment— 
The  author's  method— Introduction  of  bougies,  etc.,  to  the  rectum— Proctotomy 
—Internal  proctotomy— Bacon's  method  of  treatment  in  stricture  of  rectum 
— Eartman's  method— External  proctotomy— Operation— The  results— Proc- 
tectomy—Preparation  of  patient— Perineal  proctectomy— The  precautions— 
The  results— Sacral  proctectomy— Kraske's  operation— Exposure  of  rectum — 


CONTENTS.  yii 

PAOC 

Koclier's  method — Tiittle's  mothud — Levy's  method — Relin-Itydygier  method — 
Boreliiis's  method — The  remarks — Stages  of  removal  of  diseased  portion — Vica- 
rious spliiiK'terie  eoiitrol — Various  methods  of  attaiiiiiieiit — (Jetieral  remarks — 
Choice  of  operation — 'J'lie  results — ('olorectostouiy — Sacral  colorectostomy — 
Vaginal  proctectomy !)46 


CHAPTER  XVI. 

OPERATIONS   ON   THORAX   AND    NECK. 

Excision  of  breast — Anatomical  points — Primary  incisions — Koclier's  incision — 
Warren's  incision — Senn's  incision — Cheyne's  incision — Ilalsted's  method  of 
operation — Meyer's  method  of  operation — Less  radical  methods  of  procedure — 
General  remarks — The  after-treatment — The  results — Choice  of  operation — 
Operation  for  non-malignant  tumors — Thomas's  method — Thoracentesis — Ana- 
tomical j)oints — The  operation — The  precautions — The  results — Thoracotomy — 
Excision  of  a  portion  of  rib — The  remarks — Treatment  by  simple  incision — 
Treatment  by  aspiration  combined  with  drainage — Thoracoplasty — Estlander's 
operation — Schede's  operation — Delorme's  operal ion — The  results — Thoracoto- 
my for  caries  and  necrosis  of  ribs  and  sternum — For  tumors  of  ribs  and  ster- 
num— Feil-O'Uwyer  a[)paratus  in  action — The  precautions — The  results — 
Wounds  and  hernia  of  diaphragm — Treatment  of — The  precautions — llicmo- 
thorax — Aspiration  for — Licision  for — The  precautions — The  results — Abscess 
of  lung — The  operation — The  precautions — The  i"emarks — The  results — Bron- 
chiectasis— Treatment  of — The  results — Gangrene  of  lung — Operation — The 
precautions — The  remarks — The  results — Tumor  of  lung— The  operation — Tiie 
precautions — The  results — Tuberculosis  of  lungs — Tubercular  meningitis — 
Treatment  of — The  precautions — The  remarks — The  results — Resection  of  tu- 
berculous deposit  in  lung — Temporary  pneumothorax  in  treatment  of  pulmo- 
nary tuberculosis — Mediastinal  thoracotomy — Posterior — Author's  plan  of  prac- 
tice— Anterior  thoracotomy — Milton's  operation — Operations  on  heart  and  peri- 
cardium— Anatomical  points — Aspiration  of  pericardium — Various  methods 
of — The  resiUts — Pericardiotomy — Operation  of — The  remarks — Wounds  of 
heart — Treatment  of — The  results — Suture  of  wounds  of  heart — Operations 
on  neck — Pharyngotomy — Anatomical  points — The  after-treatment — Laryn- 
gotomy — Operation  of — Tracheotomy — Anatomical  points — Operation  below 
isthmus — Operation  above  isthmus — Operation  through  isthmus — Laryngo- 
tracheotomy — Rapid  laryngo-tracheotomy — Operation  of — Thyrotomy — Opera- 
tion of — The  precautions — General  comments — After-treatment — The  results 
of  tracheotomy — Subhyoid  pharyngotomy — Operation  of — Litubation  of  lar- 
ynx— Introduction  of  tube — After-treatment — The  results— Foreign  bodies  in 
air  passages — Methods  of  treatment — The  results — Laryngectomy — Complete 
laryngectomy — Koclier's  method  —  The  results — Treves's  method — Partial 
laryngectomy — Total  laryngectomy — Keen's  plan  of  operation — Tamponing 
the  trachea — Trendelenburg's  tampon — Ilahti-Michael's  tampon — Gerster's 
tampon — Artificial  larynx — The  results — Operations  on  thyroid  body — Ana- 
tomical points — Preparation  of  patient — Partial  excision — Kocher's  method 
— Angular  incision — Transverse  incision — Kocher's  methods — Enucleation  re- 
section— Kocher's  method — Enucleation — Socin's  method — Resection  of  goitre 
— Kocher's  method — Treatment  by  ligature  of  thyroid  arteries — By  exothyro- 
pexy — By  excision  of  sympathetic — By  injection — Dangers  of  operations — To 
recurrent  laryngeal — From  cellulitis — From  cachexia — The  results — Wounds  of 
neck — Treatment  of — Abscess  and  phlegmon  of  neck — Retropharyngeal  abscess 
— Anatomical  points — Chiene's  method  of  treatment — Buckhardt's  method — Re- 
moval of  diseased  cervical  lymphatic    glands — Anatomical   points — Treves's 


viii  OPERATIVE  SURGERY. 


PAGE 


operation — The  precautions — The  remarks — Hartley's  method — The  results — 
Branchial  cysts — Extirpation  of  parotid  gland — Anatomical  points— Contra- 
indications of — The  results 1003 

CHAPTER    XVII. 

OPERATIONS   ON  THE   URINARY  BLADDER. 

Care  of  catheters  and  sounds — Introduction  of  a  catheter  or  sound  into  bladder — 
The  comments — Retention  of  urine — Retention  from  stricture — The  comments 
— Retention  from  enlarged  prostate — Puncturing  of  bladder — Suprapubic  punc- 
ture— By  direct  incision — By  aspiration — With  trocar — Puncture  at  pubes — 
Puncture  through  rectum — Rupture  of  bladder — Intraperitoneal  rupture  of — 
Extraperitoneal  rupture  of — The  remarks — The  results — Cystotomy — Perineal 
cystotomy — Suprapubic  cystotomy — Cystotomy  for  tumors — The  operation — The 
remarks — The  results — Drainage  of  bladder — Drainage  per  urethram — Perineal 
drainage — Suprapubic  drainage — Gibson's  method  of — Dawbarn's  apparatus  for 
— The  remarks — Artificial  urethra  in  prostatic  obstruction — The  operation — 
McGuire's  method — Morris's  modification  of — Prostatectomy — Suprapubic  pros- 
tatectomy— The  operation — The  comments — The  results — Perineal  prostatec- 
tomy— The  operation — Dittel's  method — Belfield's  method — Alexander's  method 
— The  dangers  of — The  results — Enlarged  prostate,  castration  for — Operations 
on  vasa  deferentia  for — Ligature  of  iliac  arteries  for — Bottini's  method — Pros- 
tatic abscess — Operations  for — The  remarks — The  results — Excision  of  seminal 
vesicles — Extroversion  of  bladder — Operative  treatment  of — Maury's  operation 
— Bigelow's  operation — Wood's  operation — Robson's  modification  of  Wood's 
operation — Thiersch's  method — Modifications  of  Thiersch's  metliod — Trendelen- 
burg's method — Otiier  methods — Extirpation  of  bladder — Stone  in  bladder — 
Detection  of — The  comments — Bi-manual  palpation  in — The  cystoscope  in — 
Lithotrity — Contraindications — The  preparation  of  patient — Finding  and  seizing 
stone — The  precautions — The  complications — The  results — Litholapaxy — Vari- 
ous lithotrites — Various  evacuators — Various  evacuating  tubes — The  comments 
— The  precautions — The  sequels — The  results — Litholapaxy  in  children — Com- 
bined crushing  and  evacuation — Chismore's  method — The  results  of — Perineal 
lithotrity  with  litholapaxy — Dolbeau's  method — The  results — Lithotrity  in  fe- 
male— Lithotomy — The  anatomical  points — Lateral  lithotomy — Preliminary 
steps  of  operation — The  operation — Lateral  lithotomy  in  children — Complica- 
tions— Instruments  employed  in — Various  staffs — Bilateral  lithotomy — Medio- 
lateral  lithotomy — Medio-bilateral  lithotomy — Suprapubic  lithotomy — The  ana- 
tomical points — The  operation — The  complications — The  precautions — The 
results — Foreign  bodies  in  urethra — The  treatment — Foreign  bodies  in  bladder 
— The  treatment — Lithotomy  in  female — The  methods  of 1108 

CHAPTER  XVIII. 

OPERATIONS  ON  THE  SCROTUM  AND  PENIS,  AND  MISCELLANEOUS  OPERATIONS. 

Hydrocele  of  tunica  vaginalis — The  palliative  treatment — Treatment  by  injection 
— Treatment  by  incision — Treatment  by  excision — Treatment  by  partial  excision 
— Castration — The  operation — The  precautions — The  results — Orchidopexy — 
Circumcision — Keyes's  method — Roser's  method — Various  modifications — Para- 
phimosis— Steps  in  reduction  of — Amputation  of  the  penis — Various  operations 
for — Extirpation  of — Gouley's  method — Varicocele — Palliative  treatment  of — 
Radical  treatment  of — Repair  of  the  vas  deferens — Elephantiasis  of  scrotum — 
Congenital  malformation  of  urethra — Hypospadias— Gouley's  method — Anger's 
method — Duplay's  method — Szymanowski's  method — The  remarks — The  results 


CONTENTS.  ix 

PAQB 

— Kpispiidias — Nt'laton's  method — Tliiersch's  method — Dupluy's  method — I'cri- 
iical  liypdspadias  —  Urethronliaphy — rrothroplasty — U  ret  hrotumy  — Urethro- 
plasty, perineal — IVriiieal  iireliirotomy,  exteniul — With  and  without  a  guide — 
Urethra,  rupture  of — Tiie  treatment — Tlu-  preeautions — 'J'he  results — Urethrot- 
omy, internal — Ijoeatioii  of  strictures — Urethrotomes — The  operation — Comjdi- 
cations — The  results — Urethra,  tappinj^  of — Psoas  abscess — Operation  for — 'I'hc 
j)recautions — The  results — Fracture  of  patella — Suture  of — DilTerent  incisions 
for — The  operation — The  precautions — The  results — Slimson's  method  of  suture 
— Harker's  method  of  lij;ature  of — C'eci's  method  of  ligature  of — Elongation  of 
quailrice|is  tendon  in  old  fracture  of — Quadriceps  tendon,  rupture  of — Methods 
of  treatment — Olecranon  process — Fracture — Suture  of — Fractured  long  i)ones 
— Suturing  of — Wiring  of — Peripheral  and  intramedullary  pegging  of — Park- 
hill's  method  of  treatment — Nailing  head  of  femur  in  fracture  of  anatomical 
neck  of — ParkhilTs  methdd  of  lixation — Joints,  movable  bodies  in — Frontal 
sinus,  movable  bodies  in — Tlie  precautions — The  treatment — The  results — 
Frontal  sinus,  drainage  of — IMaxillary  sinus — Opening  of — The  precautions — 
Cervical  sympathetic  nerve — Operations  on — Foreign  body  in  hand — Detection 
of,  by  X  ray " 1207 


41* 


ILLUSTRATIONS. 


Abdominal  si't'tion,  patifiit  imparcd  for.     Fiy^.  774. 

Ahilomiiial  section,  instnuncnts  eiiiiiloycd  in.     VU^.  775. 

Abdominal  section,  anatomy  of  median  line.     Fi.ir.  776. 

Abdominal  section,  anatomy  of  median  line.     Fig.  777. 

Alidominal  section,  tier  suturing  in.     Figs.  779,  780. 

Abdominal  section,  suture  en  masse.     Fig.  781. 

Abscess,  retropliaryngeal  opening  of.     Fig.  1295. 

A(.lams\s  clamp.     Fig.  7iiO. 

Amputation  of  penis,  flap  method.     Figs.  1447,  1448. 

Amputation  of  penis,  transverse.     Fig.  1449. 

Amputation  of  penis,  close  to  scrotum.     Fig.  1450. 

Anal  speculum,  Tliebaud's.     Fig.  1176. 

Anal  specula.     Figs.  1181-1183. 

Anal  fistula,  irregular  forms  of.     Figs.  1184-1186. 

Anatomy  of  perinanun  and  bladder,  etc.     Fig.  1378. 

Andrew's  searcher.     Fig.  1346. 

Anus,  artificial,  Kocher's  method.     Fig.  883. 

Anus,  artiflcial,  vicarious  sphincteric  control  of.     Figs.  1226-1228. 

Anus,  artificial,  without  spur.     Fig.  937. 

Anus,  artificial,  with  spur.     Fig.  938. 

Anus,  absence  of.     Operation  for.     Figs.  1168-1170. 

Anus,  absence  of.     Figs.  1201-1204. 

Anus,  absence  of.     Figs.  1166,  1167. 

Anus,  Allingham's  director.     Fig.  1180. 

Anus,  fistulre  of.     Figs.  1172-1174. 

Anus,  fistula  of.     Allingham's  ligature  carrier.     Fig.  1187. 

Anus,  fistula  of,  ligature  carried  by  probe.     Fig.  1188. 

Anus,  instruments  employed  in  operations  on.     Fig.  1171. 

Anus,  operation  for  fistula  of     Figs.  1177-1179. 

Anus,  stretching  sphincter  of.     Fig.  1175. 

Anus,  prolapse  of.     Fig.  1206. 

Appendicitis,  instruments  employed  in  operation  for.     Fig.  922. 

Appendicitis,  superficial  and  deep  incisions  in.     Figs.  923,  924. 

Appendicitis,  Fowler's  modified  incisions  in.     Fig.  929. 

Appendi.x,  treatment  of.  Fowler's  method.     Figs.  925-928. 

Aspirator,  Potain's.     Fig.  1093. 

Autliors  combined  instrument.     Fiir.  1370. 


PAGE 

Original.  COS 

Original.  609 

Brail n,  modified.  610 

Braun,  modified.  611 

G.  Smith.      616,  617 

G.  Smith.  617 

Esmarch.  1099 

W.  F.  Ford  tfc  Co.  589 

Waring.  1223 

Esmarch.  1224 

Esmarch.  1225 

W.  F.  Ford  (&  Co.  951 

W.  F.  Ford  <&  Co.  953 

Kelsey,  modified.  954 

Gray,  modified.  1183 

Tiemann  tfc  Co.  1158 

Kocher.  672 

Lejars.       996,  997 

TiUinanns.  736 

Tillmanns.  736 

Lejars.       948,  949 

Wyeth  and  Tillmanns.  971 

Wyeth.  947 

W.  F.  Ford  cfc  Co.  952 

Van  Buren.  951 

Allingham.  955 

Esmarch.  955 

Original.  950 

Packard.  952 

Esmarch.  951 

Van  Buren.  927 

Original.  711 

Sa/oiis,  modified.  712 

Sajous,  modified.  724 

Foti'ler.      713-715 

ir.  F.  Ford  d-  Co.  897 

W.  F.  Ford  d'  Co.  1173 


Banks's  dilating  filiform  boueies.     Fisr.  1497. 
Bigelow's  operation  for  extroversion  of  the  bladder. 
Bigelow's  lithotrite  with  blades.     Figs.  1355-1357. 
Bigelow's  evacuator.     Fig.  1361. 
Bigelow's  evacuatinir  tubes.     Fig.  1365. 
Billroth's  sounding  board  and  searcher.     Fig.  1347. 
Blizard's  knife.     Fig.  1382. 
Bone  bobbin,  Rob.son's.    Fig.  823. 


Figs.  1334,  1335. 


Tiemann  d'  Co. 

Bigelow. 

W.  F.  Ford&  Co. 

W.  F.  Ford  d-  Co. 

W.  F  Ford  d  Co. 

Tiemann  d  Co. 

W.  F  Ford  d  Co. 

Robson. 

xi 


1250 
1149 
1166 
1167 
1169 
1158 
1184 
635 


Xll 


OPERATIVE  SURGERY. 


Bone  bobbin,  Allingham's.     Fig.  824. 

Bone  bobbin,  Hayes's.     Figs.  825,  82fi. 

Bone  bobbins,  Neuber's  decalcified.     Fig.  827. 

Bowel,  lower,  Kelly's  instruments  for  examination  of.     Fig.  1194. 

Bowel,  lower,  exaggerated  position  in  examination  of.     Fig.  1195. 

Bowel,  lower,  knee-cliest  position  in  examination  of     Fig.  1196. 

Brenner's  purse-string  suture  of  bladder.     Fig.  1412. 

Briggs's  modified  lithotome.     Fig.  1404. 

Browne's  air  tampon.     Fig.  1391. 

Cabot's  tampon  in  prostatectomy.     Fig.  1325. 

Ciscum  and  appendix.     Fig.  919. 

Cfficum  and  appendix,  foetal  type.     Fig.  920. 

Castration.     Fig.  1430. 

Catheter  passing  triangular  ligament.     Fig.  1303. 

Catheter  fastened  temporarily  in  place.     Fig.  1310. 

Catheterism  of  female,  instruments  employed  in.     Fig.  1085. 

Catheterism  of  female,  knee-breast  position.     Fig.  1086. 

Catheterism  of  female,  elevated  dorsal  position.     Fig.  1087. 

Catheterism  of  female,  evacuator  in.     Fig.  1088. 

Cervical  lymphatic  glands,  instruments  employed  in  the  removal.     Fig.  1296. 

Cervical  lymphatic  glands.  Hartley's  method  of  removal.     Fig.  1297. 

Cervical  sympathetic  nerve  and  ganglia,  operations  on.     Figs.  1552-1554. 

Chemise  catheter.     Figs.  1389,  1390. 

Chest  wall,  instruments  employed  in  operations  on.     Fig.  1247. 

Chismore's  evacuator.     Fig.  1364. 

Cholecystenterostomy,  Murphy's  button  in.     Fig.  1017. 

Choledocho-enterostomy,  Boari's  method.     Figs.  1023-1025. 

Choledocliorrhaphy  resection,  Doyen's  method.     Figs.  1026-1029. 

Choledochotomy,  Ilalsted's  method.     Figs.  1018-1020. 

Choledochotomy,  Abbe'.s  plan  of  drainage.     Fig.  1021. 

Choledochotomy,  exposure  of  stone.     Fig.  1022. 

Circumcision,  steps  of     Fig.  1435. 

Circumcision,  Keyes's  method.     Fig.  1436. 

Circumcision,  dorsal  slit  in.     Fig.  1437. 

Circumcision,  trimming  foreskin.     Fig.  1438. 

Circumcision,  Eoser's  operation.     Fig.  1439. 

Civiale's  histouri  cache.     Fig.  1506. 

Clamping  foreskin.     Fig.  1433. 

Clover's  crutch.     Fig.  1393. 

Colectomy,  Paul's  method.     Fig.  916. 

Colopexy,  author's  method.     Fig.  1216. 

Colorectostomy,  Kelly's  method.     Fig.  1229. 

Colostomy,  instruments  employed  in.     Fig.  889. 

Colostomy,  iliac.     Figs.  890,  891. 

Colostomy,  Bodine's  operation.     Figs.  893,  894. 

Colostomy,  iliac,  Cripps's  method.     Figs.  895,  896. 

Colostomy,  iliac,  line  of  incision.     Fig.  897. 

Colostomy,  iliac,  transverse  section  showing  anatomy  of.     Fig.  898. 

Colostomy,  iliac,  incision  made.     Fig.  899. 

Colostomy,  iliac,  structures  exposed.     Fig.  900. 

Colostomy,  iliac,  operation  continued.     Fig.  901. 

Colostomy,  iliac,  operation  completed.     Fig.  902. 

Cushing's  bladder  suture.     Fig.  1411. 


PAGE 

Allingham. 

635 

Hayes. 

636 

Tillmanns. 

636 

Original. 

964 

New  illustration. 

965 

Kelly. 

967 

Morrow. 

1200 

W.  F.  Ford  (&  Co. 

ir96 

Tiemann  c&  Co. 

1186 

Cahot. 

1133 

Original. 

708 

Original. 

709 

Esinarch. 

1215 

Zuclcerhandl. 

1110 

Esrnarch. 

1114 

Kelly. 

882 

Kelly. 

883 

Kelly. 

884 

Kelly. 

885 

)6.            Original. 

1101 

Hartley. 

1104 

Jonnesco.     1283 

-1285 

Tiemann  &  Co. 

1186 

Original. 

1022 

Tiemann  &  Co. 

1168 

Murphy. 

811 

Pantaloni. 

821 

Doyen.     821,  822 

Halsted.     816,  817 

Abhe. 

817 

Elliot. 

819 

Original. 

1218 

Keyes. 

1218 

Morrow. 

1218 

Morrow. 

1218 

Tillmanns. 

1219 

W.  F.  Ford  d'  Co. 

1255 

Gross. 

1217 

Tiemann  db  Co. 

1187 

Mayland. 

703 

Original. 

983 

Kelly. 

1001 

Original. 

676 

Dennis,  modified. 

677 

Wyeth.     679,  680 

Cripps. 

681 

New  illustration. 

683 

Braun. 

684 

Heath.,  modified. 

685 

Heath,  modified. 

685 

Heath,  modified. 

686 

Heath,  modified. 

686 

Morrow. 

1200 

Dawbarn's  apparatus  for  bladder  drainage.     Fig.  1320. 

Destruction  of  spur  by  enterotome.     Fig.  939. 

Dittel's  method  of  fastening  catheter  in  place.     Fig.  1311. 

Dittel's  operation  of  lateral  prostatectomy.     Fig.  1326. 

Dolbeau's  dilator.     Figs.  1372-1375. 

Dolbeau's  shield.     Fig.  1377. 


Dawharn.    1128 

Tillmanns.      736 

Zuckerhandl.    1114 

Dittel.    1135 

W.  F.  Ford  <&  Co.     1178-1180 

Tiemann  &  Co.     1182 


ILLLS'l'KATlUNS. 


xm 


Dolbonu's  lilhoclost.     Fig.  1384. 

Diipiiytrt'irs  knife.     Fij^.  1381. 

DupiiN  trcnV  ilouhlo  lltliutoiiie.     Fi(j.  139i'i. 

Entero-aiiastoiiiosis,  Gullet's  inethoj  niid  Weir's  inoditication.     Fig.  982. 
Enterorrliapliy,  eiivulur,  elbowiii^j  iti,  Jeannel'.s  method.     Figs.  884,  885. 
Euterorriiapliy,  cireular,  Cliaimt's  method.     Fig.  886. 
Enterorrliapliy,  eireular,  oliliiiuo  seetioii.     Fig.  887. 
Enterostomy,  Koelier'a  method.     Fig.  882. 
Enterotomes  of  Dupuytren  and  Collin.     Fig.  03G. 
Epispadia.-*,  Nelaton's  method.     Figs.  1472,  1473. 
Epispadias,  Thiersch's  method.     B'igs.  1474-1483. 
Epispadias,  Duplay's  method.     Figs.  1484,  1485. 


I'AfiE 

W.F.Ford  it;  Co.  1185 
W.  F.  Ford  <L-  Co.  1184 
(»'.  /•:  Fordd:  Co.     11  HI 


GalUl  ami  Weir. 

705 

Jiaimel. 

C73 

Jeannel. 

674 

Jeannel. 

674 

Kocher. 

671 

W.  F.  Ford  ct  Co. 

735 

Nelaton. 

1240 

Treves,  1241- 

-1243 

Treves,  1243, 

1244 

Fnx-es,  operation  for  iiioontinenec  of.     Figs.  1189-1191. 

Ficeal  listuhi  and  artiticial  anus,  diugrainmatic,  illustrations  of.    Fig.  930, 

Fivoal  fistula,  treatment  of,  G.  Smitirs  method.     Figs.  931-934. 

Fa?cnl  tistula,  treatment  of,  intestinal  spur  in.     Fig.  935. 

Fascia,  deep  cervieal,  arrangement  of.     Fig.  1294. 

Fell-O'Dwyer  apparatus.     Figs.  1258-1260. 

Femoral  region,  anatomy  of.     Fig.  1118. 

Femoral  region,  anatomy  of.     Fig.  1120. 

Fenestrated  and  non-fenestrated  jaws.     Figs.  1353,  1354. 

Filiform  bougies.     Fig.  1305. 

Fisher's  phimosis  forceps.     Fig.  1432. 

Forbes'a  lithotrite.     Fig.  1371,./. 

Forceps,  straight  and  curved  lithotomy.     Figs.  1385,  13S6. 

Foreign  body,  location  in  hand  by  X  ray.     Figs.  1555,  1556. 

Fractured  long  bones,  suture  of.     Figs.  1533-1535. 

Fractured  long  bones,  ligature  of.     Figs.  1536-1542. 

Fractured  long  bones,  pegging  of.     Figs.  1543-1547. 

Fractured  long  bones,  Parkhill's  method  of  li.xation.     Figs.  1548,  1549. 

Frontal  sinus,  drainage  of.     Fig.  1551. 

Frozen  sections  of  bladder  and  rectum.     Figs.  1405-1408. 

Gall  bladder.     Fig.  1011. 

Gall  bladder  and  biliary  ducts.     Fig.  1112. 

Gall  ducts,  instruments  for  operations  on.     Fig.  1015. 

Gastric  tistula,  .self- feeding.     Fig.  945. 

Gastro-enterostomy,  Maunsell's  method.     Fig.  809. 

Gastro-enterostomy,  anatomy  of.     Fig.  964. 

Gastro-entero.stoiny,  scheme  of  relations.     Fig.  965. 

Gastro-enterostomy,  diagrammatic.     Fig.  966. 

Gastro-enterostomy,  anterior.     Figs.  967,  968. 

Gastro-enterostomy,  anterior,  Lowenstein's  method.     Fig.  969. 

Gastro-enterostomy,  entero-anastomosis,  Wol tier's  method.     Fig.  971. 

Gastro-enterostomy,  Jaboulay's  method.     Fig.  970. 

Gastro-enterostomy,  Von  Hacker's  method.     Fig.  972. 

Gastro-enterostomy,  narrowing  pylorus.  Doyen's  method.     Figs.  973,  974, 

Gastro-enterostomy,  Chaput's  valve.     Fig.  975. 

Gastro-enterostomy,  Kocher's  method.     Fig.  976. 

Gastro-enterostomy,  Sonnenberg's  method.     Figs.  977,  978. 

Gastro-enterostomy,  posterior,  Von  Hacker's  method.     Fig.  979. 

Gastro-enterostomy,  posterior,  Von  Hacker's  method.     Fig.  980. 

Gastro-enterostomy,  Roux's  method.     Fig.  981. 

Gastro-gastrostomy.     Figs.  998-1001. 

Gastroplication.     Figs.  1002,  1003. 

Gastrostomy,  fi.xation  of  stomach,  Howse's  method.     Figs.  943,  944. 

Gastrostomy,  Witzel's  method.     Figs.  946-950. 

Ga.strostomy,  Ssabanejew-Franck.     Figs.  951,  952. 

Gastrostomy,  Senn's  (E.  J.)  method.     Figs.  953-956. 


Kelsey.     950,  957 

G.  Smith.      731 

G.  Smith.     732,  733 

8.  Smith.      734 

Gray.     1098 

Fell-CDwyer^iazi,  1034 

Gray,  modifieil.       910 

Gray,  modified.      911 

W.  F.  Ford  cfc  Co.     1165 

W.  F.  Ford  dk  Co.    1112 

W.  F.Ford  &  Co.     1217 

Original.     1174 

W.  F.  Ford  db  Co.     1185 

Original.    1286,  1287 

Zejars.     1272 

Lejars.     1273,  1274 

Zejars.     1275,  1276 

Parkhill.     1276,  1277 

Esmarch.     1281 

Morroto.    1197,  1198 

Tillaux.  803 

Testut.  804 

Original.  806 

Tillmanns.  747 

Maunsell.  628 

Modified  illustration.  755 

Esmarch.  756 

Tillmanns.  756 

New  illustration.  757 

Keen.  758 

WOlfltr.  758 

Jaboulay.  756 

Von  Hacker.  753 

Doyen.  759 

Chaput.  759 

Kocher.  760 

Dennis,  modified.  761 

Von  Hacker,  modified.  762 

Esmarch,  modified.  763 

Eoux.  764 

Keen.     781,  782 

Keen.     782,  783 

G.  Smith.     744,  745 

Dennis.  747 

Keen.  747 

Senn.  750 


XIV 


OPERATIVE  SURGERY. 


Gastrostomy,  Kader's  method.     Figs.  957-9GO. 

Gastrostomy,  Marwedel's  method.     Figs.  9(31,  962. 

Gastrotomy,  forceps  introduced  into  stomach.     Fig.  767. 

Gustrotomy  and  gastrostomy,  instruments  employed  in.     Fig.  941. 

Gibson's  method  of  bladder  drainage.     Figs.  1316-1319. 

Goitre,  excision  of  right  side,  Kocher's  method.     Fig.  1288. 

Goitre,  excision  of  left  side,  Kocher's  method.     Fig.  1289. 

Goitre,  excision  of  right  side,  transverse  incision,  Kocher's  method. 

Goitre,  excision  of  left  side,  angular  incision,  Kocher's  method.     Fi^ 

Goitre,  Kocher's  grooved  director  for  excision  of.     Fig.  1292. 

Goitre,  enucleation,  resection  of,  Kocher's  method.     Fig.  1293. 

Gorget,  blunt.     Fig.  1383. 

Gouley's  whalebone  guides.     Fig.  1306. 

Gouley's  tunneled  catheter  and  whalebone  guide.     Fig.  1307. 

Gouley's  tunneled  sound  and  whalebone  guide.     Fig.  1309. 

Gouley's  searcher.     Fig.  1345. 

Gouley's  lithoclasts.     Fig.  1376. 

Gouley's  beaked  bistoury.     Fig.  1498. 

Gouley's  grooved  director  and  tenaculum.    Fig.  1499. 

Gouley's  whalebone  guides,  full  length.     Fig.  1501. 

Grant's  enterotome.     Fig.  853. 

Grooved  lithotomy  staffs.     Fig.  1380. 

Guides  introduced  into  urethra.     Fig.  1308. 


Fig.  1290 
.  1291. 


Keen. 

Keen. 

Dennis. 

Original. 

Gihso7i.     1126, 

Kocher. 

Kocher. 

Kocher. 

Kocher. 

Tillmanns. 

Kocher. 

W.  F.  Ford  d-  Co. 

W.  F.  Ford  dt  Co. 

W.  F.  Ford  dt  Co. 

W.  F.  Ford  &  Co. 

W.  F.  Ford  <&  Co. 

W.  F.  Ford  S  Co. 

W.  F.  Ford  db  Co. 

W.  F.  Ford  <&  Co. 

W.  F.  Ford  (&  Co. 

Wyeth. 

Tlemann  <£•  Co. 

Esmarch. 


PAGE 

751 
753 
600 
740 
1127 
1088 
1089 
1090 
1091 
1092 
1093 
1184 
1112 
1112 
1113 
1157 
1181 
1251 
1251 
1251 
648 
1184 
1113 


W. 


Fig.  1550. 


Ilsemorrholds,  ligature  of.     Fig.  1192. 

Ilsemorrhoids,  Allingham's  instrument  for  crushing.     Fig.  1193. 

Harrison's  method  of  perineal  drainage.     Fig.  1315. 

Head  of  femur,  fixation  of,  in  fracture  of  neck,  Parkhill's  method 

Heart,  relations  of,  to  pericardial  effusion.     Fig.  1263. 

Henry's  phimosis  forceps.     Fig.  1431. 

Henry's  scrotal  clamp.     Fig.  1455. 

Hepatectomy.     Figs.  1005-1008. 

Hernia,  abdominal  sac  of.     Fig.  1094. 

Hernia,  intestinal  contents  of.     Fig.  1095. 

Hernia,  strangulated.     Fig.  1096. 

Hernia,  strangulated,  reduction  en  masse.     Figs.  1097,  1098. 

Hernia,  Levis's  director.     Fig.  1104. 

Hernia,  strangulated  loop.     Figs  1111, 1112. 

Hernia,  oblique  inguinal,  contents  of.     Fig.  1113. 

Hernia,  femoral  and  inguinal,  anatomy  of.     Fig.  1114. 

Hernia,  direct  inguinal.     Fig.  lllfi. 

Hernia,  femoral,  complete.     Fig.  1119. 

Hernia,  obturator,  relations  of.     Fig.  1122. 

Hernia,  lumbar.     Fig.  1123. 

Hernia,  ischiatic.     Fig.  1124. 

Hernia,  ischiatic,  anatomy  of.    Fig.  1125. 

Hernia,  retroperitoneal.     Fig.  1126. 

Hernia,  inguinal,  radical  cure  of,  Bassini's  method.     Figs,  1127-1132. 

Hernia,  inguinal,  radical  cure  of,  Ilalsted's  method.     Figs.  1133-1140. 

Hernia,  inguinal,  Halsted's  method,  Bloodgood's  moditication  of. 

Hernia,  inguinal,  radical  cure  of,  Lucas-Championniere's  method.     Fi_ 

Hernia,  inguinal,  radical  cure  of,  Kocher's  method.     Figs.  1145-1148. 

Hernia,  inguinal,  radical  cure  of,  MacEwen's  method.     Figs.  1149-1155. 

Hernia,  femoral,  radical  cure  of,  Bassini's  method.     Fig.  1156. 

Hernia,  femoral,  radical  cure  of,  Coley's  method.     Fig.  1157. 

Hernia,  umbilical,  radical  cure  of.     Fig.  1158. 

Hernia,  umbilical,  radical  cure  of,  Dauriac's  method.     Figs.  1159-1161. 

Hernia,  ventral,  radical  cure  of,  6.  Smith's  method.     Fig.  1162. 

Hernia,  inguinal,  radical  cure  of,  under  local  anaesthesia,  Cushing's  method 


Esmarch.       960 

F.  Ford  &  Co.      961 

Harrison.     1125 

ParhhiU.     1211 

Touhert.     1054 

W.  F.  Ford  &  Co.    1217 

W.  F.  Ford  <&  Co.     1228 

Pantaloni.    798,  799 

Bernard  and  Huette.      898 

Bernard  and  Iluette.      898 

Albert.       900 

Albert.      900 

W.  F.  Ford  db  Co.      904 

Bernard  and  Iluette.       907 

Bernard  and,  Huette.       908 

Bernard  and  Iluette.       908 

Bernard  and  Iluette.       909 

Bernard  and  Huette.      911 

Tillmanns.       913 

Tillmanns.       914 

Tillmanns.      914 

Tillmanns.       914 

Tillmanns.       915 

New  illvstratio7is.      916-918 

Ilalsted.     919-925 

Figs.  1141-1143. 

Bloodgood.     926-928 

1144.  Dennis.       929 

Kocher.     930-933 

MacEwen.     934,  935 

Denrris,  modified.      936 

Cole]/.      937 

G.  Smith.      938 

Sajons.     939,  940 

G.  Smith.       941 

Figs.  1163, 1164. 

dishing.     943,  944 


ILLIS'I'KATIONS, 


XV 


Ilcrninl  snc,  cystic.     Fijj.  1101. 

Ilfriiial  sue,  iloulilo.     V\<;.  1102. 

llerniotoiiiy,  iiistruiuunut  um|iloyi;d  in.     Fig.  1099. 

lleriiiotoiiiy,  iiicUiiig  suo.     Fii;.  1100. 

IluniiotDiiiy,  |>astiiiiy  Uiiifc  nloni:  fiii;,'cr.     Fig.  1103. 

Ilurniotoiny,  pus.siiig  knife  ulong  ilircetor.     Fig.  1105. 

Ilooki'il  gorgot.     Fig.  1410. 

Ilutoliiiison's  single  lithotoine.     Fig.  1.397. 

IlvilrDoele,  various  forms  of.     Figs.  1421-1420. 

llyposiiadias,  Gouley's  method  of  treatment.     Fig.  1465. 

Hypospadias,  .Anger's  method.     Figs.  1400-1468. 

Hypospadias,  DupUxy's  method.     Figs.  1409,  1470. 

Hypospadias,  Szymanowski's  method.     Fig.  1471. 


■  'AUK 

Bernnrd  and  JIuttte.  903 

Bernard  ami  Jhirtte.  903 

Oriijiiiiil.  902 

lierniird  and  Hu>tte.  908 

Bernard  and  llutttt.  904 

Bernnnl  and  Jliiette.  904 

ir.  /•:  ford  il-  Co.  1199 

\V.  F.  Ford  tfc  Co.  1191 

Tillmanns  and  Kocker.     1209,  1210 

Gouley.  1236 

Treves.  1236 

Trece».  1237 

Szymanowski.  1238 


Imphmtation,  lateral  intestinal.     Figs.  855,  856.  Dennii.      649 

Implantation,  lateral,  Maunsell's  method.     Figs.  857-860.  Maunsell.     049,  650 

Ineisioii  of  pirinieum  for  access  to  prostate,  etc.     F'igs.  13.30-1332.       Dittel  and  Esmarch.     1144-1146 
Instruments  emi)loyed  in  the  treatment  of  retention  of  urine.     Fig.  1304.  Original.     1111 

Instruments  employed  in  cystotomy  and  treatment  of  tumors  of  the  bladder.    Fig.  1314.     Orig. 
Instrutuents  employed  by  Chismore  in  litholapa.\y.     Fig.  1371.  Original. 

Instruments  employed  iu  removal  of  foreign  bodies  from  urethra  and  bladder.  F'ig.  1415.    Orig. 


1120 
1174 
1204 
1235 
1200 


Original 

Morrow 

Senn.     637-041 

Stamm.      639 

Dawharn.     641-643 

Dawbarn.      643 

Figs.  843,  844. 

Wi/eth,  modified.       644 

Abbe.       645 

Halsted.     646,  647 

Maunsell.      647 

Wyeth.      648 


Instruments  in  repair  of  urethral  defects.     F'ig.  1404. 
Interrupted  suture  of  bladder,  MaeOormac's  method.     Fig.  1413. 
Intestinal  anastomosis,  lateral,  Senn's  method.     Figs.  829-833,  835-838. 
Intestinal  anastomosis,  lateral,  Stainm's  arraugemeut  of  sutures.     Y\g.  834. 
Intestinal  anastomosis,  lateral,  Dawbarn's  potato-plate  method.     F'igs.  839-841 
Intestinal  anastomosis,  lateral,  Dawbarn's  amended  method.     Fig.  842. 
Intestinal  anastomosis,  lateral,  Kobson's  method,  segmented  rubber  plates. 

Intestinal  anastomosis,  lateral.  Abbe's  method.     Figs.  845,  846. 

Intestinal  anastomosis,  lateral,  Ilalsted's  method.     Figs.  847-851. 

Intestinal  anastomosis,  lateral,  Maunsell's  method.     Fig.  852. 

Intestinal  anastomosis,  lateral,  Grant's  method.     Fig.  854. 

Intestinal  approximation,  Maunsell's  method,  equal  segments.     Figs.  799-805.       Maunsell.     624-627 

Intestinal  approximation,  Maunsell's  method,  unequal  segments.     F'igs.  806,  807.      Maunsell.      627 

Intestinal  end-to-end  sewing,  unequal  segments.     Fig.  917. 

Intestinal  repair,  instruments  employed  in.     Fig.  861. 

Intestinal  sewing,  defective  union,  gauze  packing  in.     Fif.  918. 

Intestinal  suture,  continuous.     Fig.  782. 

Intestinal  suture,  Gely's.     Figs.  783,  784. 

Intestinal  suture,  Cushing's.     Figs.  785,  786. 

Intestinal  suture,  Lembert's.     F'ig.  787. 

Intestinal  suture,  Czerny-Lembert.     Fig.  788. 

Intestinal  suture,  Wolfler's.     Figs.  789,  790. 

Intestinal  suture,  Gussenbauer's.     Fig.  791. 

Intestinal  suture,  Halsted's.     Fig.s.  792,  793. 

Intestinal  suture,  .Jobert's.     Figs.  794-796. 

Intestinal  suture,  Jobert's,  relation  of  surfaces  in.    Fig.  797. 

Intestinal  suture,  Jobert's,  Senn's  modification  of.     Fig.  798. 

Intestinal  suture,  transverse  defect  in.     Fig.  863. 

Intestinal  suture,  transverse  defect  repaired.     Fig.  864. 

Intestinal  suture,  elbowing  of  intestine.     Figs.  865,  866. 

Intestinal  suture,  in  unequal  segments.     Fig.  867. 

Intestinal  suture,  means  employed  to  restrain  intestinal  contents.     Fig.  868. 

Intestinal  suture,  control  of  ends  durimr  sewinir.     Fig.  869. 

Intestine,  resection  of,  Kocher's  method.     Fitrs.  870-872. 

Intestine,  resection  of,  Ilalsted's  method.     Figs.  873-876. 

Intestine,  resection  of.  Harris's  method.     Fiir.  877. 

Intestine,  resection  of,  treatment  of  mesentery,  V-shaped  incision.     Figs.  878,  879.     Fumarcfi.       665 

Intestine,  resection  of,  Ilalsted's  method.     Fi?.  880.  ffahftd.      665 

Intestine,  resection  of,  Mitchell-Hunter  suture.    Fig.  881.  Halsted.      665 


Jeannel. 

707 

Original. 

655 

'nnis,  modified. 

707 

Esmarch. 

619 

Otis.     619, 

620 

Cushing. 

620 

Esmarch. 

621 

Esmarch. 

621 

Zucl-erhaudl. 

622 

Esmarch. 

622 

Halsted. 

622 

Esmarch. 

623 

Esmarch. 

623 

Senn. 

624 

Jeannel. 

656 

Jeannel. 

657 

Jeannel. 

657 

Dennis. 

658 

Original. 

659 

<7.  Smith. 

660 

Kocher.     660, 

661 

Halsted.     662, 

663 

Harris. 

664 

XVI 


OPERATIVE   SURGERY. 


PAGE 

Introduction  of  catheter,  iirst  Step.     Fig.  1300.  Esmarch.  1109 

Introduction  of  catheter,  second  step.     Fig.  1301.  Esmarch.  1109 

Introduction  of  catheter,  tliird  step.     Fig.  1302.  Esmarvh.  1110 

Intussusception,  vertical  section  of.     Fig.  903.  New  illustration.  690 

Intussusception,  double.     Fig.  904.  Tillmanns.  691 

Intussusception,  transverse  section  of.     Fig.  905.  i\'«w  illustration.  691 

Intussusception,  longitudinal  section.     Fig.  906.  Hew  illustration.  693 

Intussusception,  specimen  of.     Fig.  907.  Wyeth.  694 

Intussusception,  treatment  of,  MaunselPs  method.     Fig.  908.  Maunsell.  696 

Intussusception,  treatment  of.  Barker's  method.     Fig.  909.  Ifetv  illustration.  696 

Intussusception,  treatment  of,  Paul's  method.     Figs.  910,  911.  New  illustration.  697 

Intussusception,  ileo-csecal,  treatment  of,  Baracz's  method.     Figs.  912,  913.  JBaracz.  698 

Intubation,  instruments  employed  in.     Fig.  1277.  Original.  1072 

Intubation,  operation  of.     Figs.  1278-1282.  Lejars.     1073-1075 

Invaginated  catheter.     Fig.  1500.  Gouley.  1251 

Ischio-rectal  spaces.     Fig.  1198.  Gray.,  modified.  969 


Figs.  1367,  1368. 


Fig.  1036. 
Fig.  10.37. 


Keyes's  tampon  in  prostatectomy.    Fig.  1324. 

Keyes's  modified  blades.     Figs.  1358, 1359. 

Keyes's  straight  and  curved  evacuating  tubes 

Keyes's  needle.     Fig.  1460. 

Keyes's  needle  in  operation.     Fig.  1461. 

Kidney,  left,  surgical  anatomy  of.     Figs.  1032, 1033 

Kidney,  right,  surgical  anatomy  of.     Fig.  1034. 

Kidney,  instruments  in  operations  on.     Fig.  1035. 

Kidney,  incision  in  exposure  of,  Simon's  position. 

Kidney,  incision  in  exposure  of,  Lange's  position. 

Kidney,  linear  guides  to  operations  on.     Fig.  1042. 

Kidney,  anatomy  of,  incisions  in  operations  on.     Fig.  1043. 

Kidney,  line  of  incision  to.     Fig.  1044. 

Kidney,  suture  of.     Figs.  1046,  1047. 

Kingsley's  interdental  splint.     Fig.  743. 

Langenbeck's  hook.    Fig.  1271. 

Laplace  forceps.     Figs.  817,  818. 

Laplace  forceps,  end-to-eud  approximation  with.     Fig.  819. 

Laplace  forceps  in  position.     Fig.  820. 

Laplace  forceps,  sutures  placed.     Fig.  821. 

Laplace  invagination  forceps.     Fig.  822. 

Larynx,  artificial,  Gussenbauer's.     Fig.  1287. 

Larynx,  topography  of.     Fig.  1268. 

Larynx  and  trachea,  surgical  anatomy  of.     Fig.  1269. 

Larynsrotomy  and  tracheotomy,  incisions  in.     Fig.  1272. 

Larynx  and  trachea,  lines  of  incision  for  operations  on.     Fig.  1273. 

Lateral  incision  of  prostate.     Fig.  1394. 

Leiter's  cystoscope.     Fig.  1349. 

Lembert's  interrupted  suture.     Fig.  862. 

Lithotomy,  perineal,  lines  of  incision  in.     Fig.  1402. 

Lithotrite  in  urethra.     Fig.  1350. 

Little's  searcher.     Fig.  1344. 

Little's  lithotomy  staff.     Fig.  1398. 

Little's  director.     Fig.  1401. 

Liver,  instruments  for  operations  on.     Fig.  1004. 

Liver,  sewing  of.     Figs.  1009.  1010. 

Liver,  vessels  of.     Fig.  1013. 

Liver,  relations  under  surface  of.     Fig.  1014. 


Keyes.  1132 

W.  F.  Ford  &  Co.  1166 

W.  F.Ford  &  Co.  1169 

W.  F.  Ford  (b  Co.  1230 

Morrow.  1230 

Esmarch.     824,  825 

Gray.  826 

Original.  827 

Esmarch.  828 

Esmarch.  828 

New  illustration.  832 

Treves.  833 

Morris.  837 

Lejars.  848 

Kingsley.  574 

W.  F.  Ford  <&  Co.  1063 

Laplace.  631 

Laplace.  632 

Lajjlace.  633 

Laplace.  633 

Laplace.  634 

Tillmanns.  1086 

Esmarch.  1060 

Seath.,  modified.  1061 

Heath,  modified.  1064 

Tillmanns.  1065 

Morrow.  1188 

Tillmanns.  1159 

Esmarch.  656 

Zuclcerkandl.,  modified.  1194 

Morrow.  1161 

W.  F.  Ford  &  Co.  11-57 

W.F.Ford&  Co.  1192 

W.  F.  Ford  &  Co.  1193 

Original.  792 

Pantaloni.  801 

G.  Smith.  805 

Henle.  805 


Mammary  gland,  lymphatic  associations  of     Fig.  1230. 
Mammary  gland,  instruments  for  excision  of.     Fig.  1231. 
Mammary  gland,  incisions  for  excision  of.    Figs.  1232-1236. 

Kocher,  Warren.,  Cheyne,  and  Senti 


Waring.     1004 
Original.     1005 


1006-1009- 


ILLUSTKA'llUNH. 


xvu 


Maiimmrv  jrlunil,  excision  of,  IlftlsteiPs  method.     Fij^a.  1^37 

Miniiiiiaiy  ^'liiiul,  exeisioii  of,  Meyer's  iiietliod.     Fij{n.  1^10, 

Maininary  jflaiid,  excision  of,  conservative  niotliod  so  culled. 

Mammary  f^'laiul,  excision  of,  Tliomas's  method.     Fig.  1245. 

Manner  of  lioklin}^  evacuator.     Fig.  13(J'J. 

Murkoc's  lithotomy  stall'.     Fig.  lu'J'J. 

Maury's  operation  for  extroversion  of  bladder.     Fig.  1838. 

Motiiod  of  holding  lithotrito.     Fig.  1351. 

Mikulicz's  taiiii>on.     Fig.  1342. 

Morgan's  suspensory.     Fig.  1454. 

Morris's  oi)eration  for  artificial  urethra.     Figs.  1821-1823. 

Murphy's  button.     Fig.  810. 

Murphy's  button,  seized  for  introduction.     Figs.  812,  813. 

Mur|>hy's  button,  joining  parts.     Fig.  814. 

Murphy's  button,  oblong.     Fig.  815. 

Murphy's  button,  purse-string  suture  employed.     Fig.  816. 

Murphy's  button,  in  cholecystotomy.     Fig.  1016. 


Nares,  plugging  of     Fig.  746. 

Narcs,  instruments  employed  in  treatment  of.    Fig.  747. 

Nasal  polypi,  .snaring  of.     Fig.  748. 

Nasal  polypi,  snaring  of,  cannula  for.     Fig.  749. 

Nasal  polypi,  loops  applied  to.     Fig.  750. 

Nasal  polypi,  Chassaignac's  method  of  incision.     Fig.  751. 

Na-sal  polypi,  Chassaignac's  method,  flap  turned  aside.     Fig.  752. 

Nasal  polypi,  Ollicr's  method  of  treatment.     Fig.  753. 

Nasal  polypi,  Lawrence's  method.     Fig.  753. 

Nasal  polypi,  Rouge's  method.     F'ig.  754. 

Nasal  polypi,  Langcnbeck's  method.     Fig.  755. 

Nasal  polypi,  Boeckel's  method.     Fig.  755. 

Niisal  polypi,  Langcnbeck's  method,  continued.     Fig.  756. 

Nasal  polypi,  Nelaton's  method.    Fig.  757. 

Nasal  polypi,  Chalot's  method.     Fig.  757. 

Nasal  polypi,  Ollicr's  incision.     Fig.  758. 

Nasal  polypi,  Guerin's  incisions.     Fig.  758. 

Nasal  polypi,  Langcnbeck's  incision.    Fig.  758. 

Nasal  polypi,  Kocher's  method.    Fig.  759. 

Nephrectomy,  kidney  and  vessels  exposed.     Fig.  1045. 

Nephropexy,  Senn's  method.     Figs.  1038,  1039. 

Nephropexy,  Morris's  method.     Fig.  1040. 

Nephropexy,  Vulliet's  method.     Fig.  1041. 

Nitze's  cyetoscope.    Fig.  1348. 

Obturator  artery,  relations  of.     Fig.  1121. 

CEsophagus,  instruments  for  removal  of  foreign  bodies  in.     Fig.  762. 

(Esophagus,  introducing  tube  into.     Fig.  763. 

CEsophagus,  instruments  employed  in  stricture  of.     Fig.  768. 

CEsophagus,  treatment  of  stricture  of,  Abbe's  method.     Fig.  769. 

(Esophagus,  stricture  of,  making  stricture  tense.    Fig.  770. 

CEsophagus,  stricture  of,  method  of  treatment.     Fig.  771. 

CEsophagus,  stricture  of,  author's  method  of  application  of  treatment. 

CEsophagus,  stricture  of,  tubage  treatment.     Fig.  773. 

CEsophagotomy,  instruments  employed  in.     Fig.  764. 

(Esophagotoiuy,  jirimary  incision  in.     Fig.  765. 

CEsophagotomy,  tinal  incision.     Fig.  766. 

Olecranon  process,  suture  of.     Figs.  1531,  1532. 

Omental  graft,  Senn's  method.    Fig.  888. 

Omentum,  tying  otf.    Figs.  1109, 1110. 

Otis's  evacuator.     Figs.  1362.  1363. 

Otis's  bougies  a  boule.    Fig.  1507. 


-1289.  Ilahted.     lOlO 

1241.  il<ytr.     1013, 

FigH.  1242-1244.    KxmarcU.     1010, 
Warren  and  Gould,  modified. 
KeijtK. 
II'.  /•:  Ford  d.-  (Jo. 
Maury. 


Keyes. 
Mikulicz. 

n:  /■:  Ford  .t  co. 

Morrill.  1129 
Murphy. 
Murphy. 
Murphy. 
Mwphy. 
Murphy. 
Murphy. 

Esmarch,  modified. 

Original. 

Esmarch. 

Packard. 

Esmarch. 

Ehinarch. 

Esmarch. 

Enriinrch. 

Esmarch,  modified. 

Esmurch. 

Esmarch,  modified. 

Esmarch,  modified. 

Esmarch. 

Treves. 

Treves. 

New  illustration. 

New  illustration. 

New  illustration. 

Tillinanns. 

Morris. 

Senn. 

Morris. 

Morris. 

Tillmanns. 

Gray,  Tnndified. 

Original. 

Esmarch. 

Original. 

Abbe. 

Abbe. 

Original. 

Original. 

Dennis. 

Original. 

Esmarch. 

Esmarch. 

Lejars. 

Senn. 

Lejars. 

IF.  F.  Ford  d'  Co. 

W.  F.  Ford  dt  Co. 


Fig.  772 


I'ACIK 

-1012 

1014 

1017 

1020 

1170 

1192 

1148 

1168 

1155 

1227 

1130 

C29 

629 

630 

630 

631 

808 

579 
580 
581 
581 
581 
582 
582 
582 
582 
583 
583 
588 
588 
584 
584 
586 
586 
586 
587 
842 
829 
830 
831 
1159 

912 
592 
593 
601 
603 
603 
604 
604 
606 
595 
596 
597 
1272 
675 
906 
1168 
1255 


XVlll 


OPERATIVE  SURGERY. 


Otis's  urethrometer.     Fig.  1508. 
Otis's  curved  urethrotome.     Fig.  1509. 
Otis's  straight  urethrotome.     Fig.  1510. 


PAGE 

rr:  F.  Ford  tt  Co.  1255 
W.  F.  Ford  <&  Co.  1256 
W.  F.  Ford  &  Co.     1256 


Paracentesis  abdominis,  instruments  employed  in.     Fig.  1091. 

Paracentesis  abdominis  with  trocar.     Fig.  1092. 

Paraphimosis.     Figs.  1440-1445. 

Patella  and  long  bones,  instruments  employed  in  repair  of  fractures  of. 

Patella,  suture  in  fracture  of.     Figs.  1515-1518. 

Patella,  fracture  of,  wire  introduced.     Fig.  1519. 

Patella,  fracture  of,  Stimsou's  method  of  treatment.     Fig.  1520. 

Patella,  fracture  of.  Barker's  method.     Figs.  1521-1523. 

Patella,  fracture  of,  Ceci's  method.     Figs.  1524,  1525. 

Patella,  old  fracture  of,  elongation  of  quadriceps  in.     Figs.  1526,  1527. 

Paul's  tubes.     Fig.  892. 

Peet's  urethrotome.     Fig.  1511. 

Pelvis,  anatomy  of,  transverse  section.     Fig.  921. 

Pericardium,  anatomy  of,  operations  of.     Figs.  12G4-1266. 

Perinseum,  anatomy  of.     Figs.  1331,  1332. 

Perineal  section,  instruments  employed  in.     Fig.  1494. 

Perineal  urethrotomy,  external.     Fig.  1496. 

Peritoneal  cavity,  drainage  of.     Fig.  778. 

Pharyngotomy,  subhyoid.     Fig.  1276. 

Pharyngotomy,  Cheever's  incision.     Fig.  745. 

Pharyngotomy,  Mikulicz's  incision.     Fig.  745. 

Pharyngotomy,  author's  secondary  incision.     Fig.  745. 

Poupart's  ligament,  transverse  section  below.     Fig.  1171. 

Pritchard's  anklets  and  wristlets.     Fig.  1392. 

Proctectomy,  perineal,  AUingham's  metliod.     Figs.  1222,  1223. 

Proctectomy,  incisions  of  sacrum.     Fig.  1224. 

Proctectomy,  sacral  incisions.     Fig.  1225. 

Prostate,  enlarged,  sections  of.     Figs.  1328,  1329. 

Prostate,  enlarged,  transverse  sections  of.     Fig.  1327. 

Prostate,  incision  to  reach.     Fig.  1330. 

Psoas  abscess,  instruments  employed  in  operation  for.     Fig.  1513. 

Pylorectomy,  Maunsell's  method.     Fig.  808. 

Pylorectomy.     Figs.  987-991. 

Pylorectomy,  decalcified  bone  tube  in.     Fig.  992. 

Pyloroplasty.     Figs.  995-997. 

Pylorus,  resection  of.     Fig.  986. 

Pylorus,  resection  of.     Figs.  993,  994. 

Quadriceps  e.xtensor  tendon,  rupture  of.     Figs.  1528-1530. 

Kanula.     Fig.  744. 

Kectal  bougies.     Fig.  1165. 

Kectal  bougie,  introduction  of     Fig.  1217. 

Kectum,  instruments  employed  in  operations  on.     Fig.  1197. 

Eectum,  imperforate.     Fig.  1199. 

Kectum,  imperforate.     Fig.  1200. 

Kectum,  imperforate.     Fig.  1205. 

Kectum,  prolapse  of.     Figs.  1207,  1208. 

Kectum,  prolapse  of,  treatment,  Roberts's  method.     Fig.  1209. 

Kectum,  prolapse,  amputation  of,  Mikulicz's  method.     Fig.  1210. 

Kectum,  prolapse  of,  Tuttle's  method  of  treatment.     Figs.  1211-1214. 

Kectum,  prolapse  of,  Peters's  method  of  treatment.     Fig.  1215. 

Kectum,  stricture  of.  Bacon's  method  of  treatment.     Figs.  1218-1221. 

Kemoval  of  stone  with  fingers.     Fig.  1414. 

Removal  of  pin  from  urethra.     Figs.  1418-1420. 

Retrograde  catheterism.    Fig.  1505. 

Ricord's  loops.     Fig.  1462. 


Original. 

896 

S.  Smith. 

897 

Old  edition.     1220, 

1221 

Fig.  1514.     Original. 

1261 

Cheyne.     1262,  1263, 

,1265 

Old  edition. 

1265 

Stimson,  modified. 

1266 

Sajous.     1267, 

,1268 

Lejars. 

1268 

Neio  illustrations. 

1269 

Jacobson. 

678 

W.  F.  Ford  tO  Co. 

1256 

Tillaux. 

710 

Toubert.     1055, 

1056 

Eocher.     1145, 

,1146 

Original. 

1248 

'Doty. 

1250 

G.  Smith. 

614 

Kocher.,  modified. 

1071 

JVew  illustration. 

576 

Mew  illustration. 

576 

New  illustration. 

576 

Tillmanns,  modified. 

910 

W.  F.  Ford  d-  Co. 

1186 

Jacobson. 

989 

Gray,  modified. 

991 

Dennis,  m,odified. 

993 

Alexander.     1138, 

1139 

Alexander. 

1137 

New  illustration. 

1144 

Original. 

1259 

Maunsell. 

628 

New  illustration.     772 

,  773 

G.  Smith. 

773 

New  illustration. 

778 

Kocher. 

771 

Kocher.    774 

,  775 

Lejars.     1270, 

1271 

Tillmanns. 

575 

Tillmanns. 

946 

Esmarch. 

984 

Original. 

968 

Wyeth. 

970 

Gross. 

970 

Tillmanns. 

972 

Van  Buren. 

975 

Roberts. 

977 

Mikulicz. 

978 

Tvttle.     980 

,  981 

Warren  and  Gould. 

982 

Bacon.     985,  986 

,  987 

Esmarch. 

1202 

Lejars. 

1207 

Lejars. 

1253 

Morrow. 

1230 

llvl.lS'l'liA'nuNS. 


XIX 


Robson'H  rul)l>or-tul)(i  hohhiri.     Fij;.  H'J8. 

Kobson's  inoilllii'ittion  of  Wood's  oixTatioii.     FijfH.  1338-1341. 

Rubber  l>ii^  lor  ili.stiiitioii  of  rcftum.     Ki^f.  HOU. 

Rubber  bii>;  for  iiijrcliii>r  byilroeelu.     V\^.  H'M. 

Rupture  of  urotlirii,  iiu-oiiipli'tc.     V'm.  \M'2. 

Rupture  of  urullira,  iiK-uiiiplctu,  suture  of.     Fig.  1503. 

Rupture  of  uri'tlirii,  coiiipk'to.     Fiy.  IMi. 

Siiliviiry  tistula,  Sctuti's  tnetliod  of  treutiiijiit.     Fij^.  T-'J'l. 

Siiliviiry  fistula,  Desault's  method  of  trcutiiieiit.     Fij;.  731. 

Salivary  ti.stuhi,  liit-hulot's  tuetlioil  of  treatment.     Fifj.  73'2. 

Salivary  fistula,  Ueipiise's  tiiellioil  of  treatment.     Fij^.  733. 

Sooop  and  eoiiiluotor.     Fij^.  1.'>S4. 

Septum,  nasal  division  of,  in.struincnts  employed  in  treatment  of. 

Small  inti'stine,  transverse  seetion  of.     Fi|j:.  811. 

Smith's  lithotome.     Fig.  1395. 

Stall,  reetani,nilar. 

Stomach,  contij,'uous  anatomy  of,  etc.    Fig.  940. 

Stomaeh,  relations  of.     Fig.  942. 

Stomach,  relations  and  vascular  supply  of.     Fig.  984. 

StonuK'h,  instruments  employed  in  operations  on.     Fig.  983. 

Stomach,  posterior  surface  of.     Fig.  985. 

Stomach,  apparatus  for  washing  out.     Fig.  110(3. 

Stomach,  washing  out,  method  of.     Figs.  1107,  1108. 

Strangulation,  intestinal,  internal,  from  diverticulum.     Fig.  914. 

Strangulation,  intestinal  ligamentous  bands.     Fig.  915. 

Subdiaphragnuitic  space,  exposure  of.     Fig.  1090. 

Suprapuliic  cystototuy.     Fig.  1312. 

Suprapubic  puncture  of  bhuUler.     Fig.  1313. 

Suture  of  urethra.     Figs.  141G,  1417. 

Syme's  grooved  staff.     Fig.  1495. 

Tapping  hydrocele.     Fig.  1427. 

Taylor's  phimosis  forceps.     Fig.  1434. 

Thom[)son's  searcher.     Fig.  1343. 

Thompson's  litliotrite.     Fig.  1352. 

Thomyison's  evacuator.     Fig.  1360. 

Thoracentesis.  Fitch's  aspirator  for.     Fig.  1246. 

Thoracotomy,  operation  of.     Figs.  1248-1251. 

Thoracoplasty,  Schede's  method.     Fig.  1257. 

Thoracotomy,  posterior,  author's  method.     Figs.  1261,  1262. 

Thora.v,  resection  of  border  of.     Figs.  1030,  1031. 

Tliora.\,  aspiration — drainage,  author's  method.     Figs.  1252-1256. 

Thyroid  gland,  surgical  anatomy  of.     Fig.  1298. 

Tongue,  e.\cision  of,  instruments  employed  in.     Fig.  734. 

Tongue,  excision  of,  V-shaped  piece.     Fig.  735. 

Tongue,  excision  of,  flaps  united.     Fig.  736. 

Tongue,  excision  of,  Jae<rer's  incision.     Fig.  738. 

Tongue,  excision  of,  Kochers  incision.     Fig.  738. 

Tongue,  excision  of,  Scdillot's  incision.     Fig.  739. 

Tongue,  excision  of,  Roux's  incision.     Fig.  739. 

Tongue,  excision  of,  Syme's  incision.     Fig.  739. 

Tongue,  excision  of,  Regnoli's  incision.     Fig.  739. 

Tongue,  excision  of,  Billroth's  incision.     Fig.  739. 

Tongue,  excision  of.  Baker's  metliod.     Fig.  740. 

Tongue,  excision  of,  Billroth's  submental  incision.     Fig.  741. 

Tongue,  excision  of,  Langenbeck's  incision.     Fig.  742. 

Tongue,  hypertrophy  of.     Fig.  737. 

Trachea,  instruments  for  operations  on.     Fig.  1270. 

Trachea,  opening  of.     Fig.  1274. 

Trachea  tampon,  Trendelenburg's.    Figs.  1283, 1284. 


I'AUIC 

New  illuntration.  637 

liiihHdii  1151 

TUinann  db  Co.  1199 

W.  F.  Ford  d-  Co.  121!4 

Lejam.  1 25!i 

Lejart.  1 25'Z 

Lejarx.  1  'iL'i 

(irons.  563 

Ferrer.  663 

Ftrrer.  564 

Ferrer.  564 

W.  F.  Ford  d-  Co.  1184 

Fig.  761.                (Jritjiiial.  590 

Murplii/.,  modified.  629 

\V.  F.  Fordilc  Co.  1190 

W.  F.  Ford  A  Co.  1192 

Gray.,  modified.  738 

Gnii/.  742 

Gray,  modified.  768 

Oriyinal.  1f,1 

Ifenle.  770 

Tillman  US.  905 

jS'.  Siiiitk.  905 

Tillmaniis.  701 

Tillmanns.  701 

Koeher,  modified.  894 

Ziiclcerkandl.  1115 

Zuckerkandl.  1116 

Lejars.     1205,  1206 

W.  F.  Ford  &  Co.  1249 

Erniarch.  1211 

W.  F.  Ford  d;  Co.  1218 

W.  F.  Ford  d-  Co.  1157 

W.  F.  Ford  d  Co.  1165 

Tiemann  cD  Co.  1167 

W.  F.  Ford  d'  Co.  1020 

Lejnrs.     1023-1025 

Esmarch.  1030 

Original.     1048,  1049 

Toubert.  823 

Original.     1026-1028 

Esmarch.  1106 

Original.  567 

.S'.  Smith.  568 

IS.  Smith.  568 

Esmarch,  modified.  570 

Kochir.  570 

Sedillot.  571 

Rou.T.  571 

Syme.  571 

Kegnoli.  571 

Billroth.  571 

Esmarch.  572 

Esmarch.  573 

Esmarch.  573 

S.  Smith.  568 

Original.  1062 

Esmarch.  1066 

Tillmanns.  1084 


XX 


OPERATIVE  SURGERY. 


Trachea  tampon,  Hahn  and  Michael.    Fig.  1285. 

Trachea  tampon,  Gerster's.     Fig.  1286. 

Tracheal  tube  in  position.     Fig.  1275. 

Tracheotomy  tubes,  comparative  diameters  of.     Fig.  1267. 

Transverse  sections  of  penis.     Fig.  1446. 

Transver.-<e  section  of  cord.     Fig.  1453. 

Triangular  ligament.    Fig.  1379. 

Ureter,  instruments  for  operations  on.     Fig.  1048. 

Ureter,  implantation  of,  Kelly's  method.    Fig.  1060. 

Ureter,  bowel  implantation  of,  Martin's  method.     Figs.  1061, 1062. 

Ureter,  implantation  of,  Fowler's  method.     Figs.  1063-1067. 

Ureter,  resection  lower  end  of,  Kelly's  method.     Figs.  1068,  1069. 

Ureter,  valve  formation,  Kiister-Trendelenburg  method  of  treatment. 


PAGE 

Tillman  ns. 

1085 

Gerster. 

1085 

Esniarch. 

1066 

Treves,  modified. 

1059 

Morrow. 

1222 

Treves. 

1227 

march,  modified. 

1138 

Original.      851 

Kelly.      859 

Martin.     862,  863 

Fowler.     864,  865 

Kelly.     868,  869 

Figs.  1070,  1071. 

Fenger,  modified.      871 
Fenger.    871,  872 
Gerster.      873 


Ureter,  valve  formation,  Fenger's  method.     Figs.  1072-1074. 

Ureter,  valve  formation,  Gerster's  method.     Figs.  1075,  1076. 

Ureter,  stricture  upper  end  of,  Fenger's  method  of  treatment.    Figs.  1077, 1078. 

Ureter,  stricture  of,  Morris's  method.     Fig.  1079. 

Ureter,  stricture  of,  Fenger's  method.     Fig.  1080. 

Ureter,  resection  of,  Kiister's  method  of  treatment.    Figs.  1081,  1082. 

Ureter,  resection  upper  end  of,  Morris's  method.     Figs.  1083,  1084. 

Uretero- ureteral  anastomosis,  Tauffer's  method.     Fig.  1049. 

Uretero-ureteral  anastomosis,  Schopf- Gushing,  etc.     Fig.  1050. 

Uretero-ureteral  anastomosis,  Bovee's  method.     Fig.  1051. 

Uretero-ureteral  anastomosis,  Markoe's  method.     Fig.  1052. 

Uretero-ureteral  anastomosis,  Poggi's  method.     Fig.  1053. 

Uretero-ureteral  anastomosis,  Eobson-Winslow  method.    Fig.  1054. 

Uretero-ureteral  anastomosis.  Van  Hook's  method.     Fig.  1055. 

Uretero-ureteral  anastomosis,  Emmet's  method.     Figs.  1056,  1057. 

Uretero-ureteral  anastomosis,  Kelly-Bloodgood  method.     Figs.  1058, 1059. 

Kelly  and  Bloodgood. 

Jacohson. 

Esmarch. 

Zuckerkandl. 

Fig.  1491.  Esmarch. 

Esmarch. 
Old  edition. 


Fenger. 

Morris. 

Fenger. 

Fenger. 

Morris. 
Markoe. 
Marhoe. 
Bovee. 
Markoe. 
Markoe. 
Markoe. 
Van  Hook. 


874 
875 
875 
876 
877 
854 
854 
855 
855 
856 
856 
857 


Urethra,  tapping  of.     Fig.  1512. 
Urethrorrhaphy.     Figs.  1486-1488. 
Urethroplasty.     Figs.  1489,  1490. 
Urethroplasty,  Nelaton's  method. 
Urethroplasty,  Dieffenbach's  method.     Fig.  1492. 
Urethroplasty,  Kigaud's  method.     Fi^.  1493. 


Urines,  differentiation  of,  Harris's  method.     Fig.  1089. 

Van  Buren's  debris  syringe.     Fig.  1388. 
Varicocele,  occlusion  by  pins.     Fig.  1456. 
Varicocele,  occlusion  by  wires.     Figs.  1457-1459. 
Varicocele,  Howse's  method  of  treatment.     Fig.  1463. 
Vessels  of  testes  and  cord.     Figs.  1451,  1452. 
Vessels,  epigastric  and  obturator.     Fig.  1115. 
Volkmann's  incision  in  hydrocele.     Fig.  1429. 

Warren's  spiral-tipped  evacuating  tube.     Fig.  1366. 

Wood's  operation  for  extroversion  of  the  bladder.     Figs.  1336, 1337. 

Wood's  staff  and  bisector.     Fig.  1403. 


Emmet.     857,  858 


858 
1258 
1245 
1245 
1246 
1246 
1246 

887 


Harris. 

W.  F.  Ford  &  Co. 

Packard. 

Gross. 

Treves. 

Uenle. 

Gray,  modified. 

Esmarch. 


1185 
1229 
1229 
1231 
1226 
909 
1213 


Tl'.  F.  Ford  d-  Co.    1169 

Treves.    1150 

W.  F.  Ford  (t  Co.    1195 


OPERATIVE    SURCiEliY. 


('11AI''I"KK    Xlll. 
OrFIi'ATIOXS   ().\    THE   JlOCT//,  /'IlAinWX,   NOSE,  AM)   (ESOl'IlAd US. 

Salivary  Fistula. — In  salivary  fistula  the  saliva  is  discharged  on  tlie 
external  surface  of  the  cheek  instead  of  into  the  mouth.  Tlie  object  of  an 
operation  is  to  establisli  an  internal  comiiiuuieation  with  the  duct  so  that 
the  external  opening  can  heal. 

The  cure  may  first  be  attempted  by  the  older  method  of  passing  the 
ends  of  several  long  silken  threads  through  the  external  opening,  directly 
into  the  mouth  or  through  the  internal  opening  of  the  duct,  and  bringing 

them  out  at  the  angle  of  the  mouth  and  tying 
their  extremities  (Fig.  730).  An  internal  com- 
munication is  easily  established  in  eight  or  ten 
days,  then  the  seton  can  be  removed  and  the  bor- 
ders of  the  external  opening  freshened  and  closed. 
During  the  healing  of  the  external  opening  the 
patient  should  be  advised  to  chew  upon  the  op])o- 
site  side  in  order  to  limit  as  much  as  possible  the 
flow  of  saliva  on  the  diseased  side. 

Agnew's  Method. — Agnew's  method  consists 
in  passing  a  good-sized  thread  of  silk  into  the 
mouth,  through  the  fistula,  from  without  inward, 
and  leaving  it  there,  removing  the  needle  and 
attacliing  to  it  the  end  of  the  thread  remaining 
outside,  and  carrying  it  through  the  tissues  into 
the  mouth  in  the  same  direction  as  the  former,  but  not  exactlv  in  the  same 
track,  thus  including  a  small  portion  of  buccal  tissue.  The  needle  is  then 
removed,  and  the  extremities  of 
the  thread  are  firmly  tied  within 
the  mouth  or  round  the  inclosed 
tissue.  A  fine  rubber  ligature 
can  be  substituted  for  the  silk. 
The  loop  cuts  its  way  through 
the  tissues  grasped,  forming  an 
internal  opening,  which  permits 
the  healing  of  the  external  one. 
Desanlfs  Method. — Desault 
carried  a  small  trocar  from  the  fistulous  opening  forward  and  inward,  enter- 
ing the  mouth  opposite  to  the  second  molar  tooth  (Fig.  T31).  A  seton 
42  563 


Fig.    730.— Seton    method 
treatment. 


of 


Fi(i.  731. — Desault's  method. 


564 


OPERATIVE  SURGERY. 


Fig.  732. — Richelot's  method. 


was  drawn  into  the  channel  made  by  the  instrument  and  retained  until  a 
patent  canal  was  formed  through  which  the  saliva  flowed,  followed  by  healing 
of  the  external  opening. 

Van  Bureii's  Method. — Van  Buren  cured  an  obstinate  case  by  turning 
the  end  of  the  duct  into  the  mouth  in  the  following  manner :  A  small  probe 
was  introduced  into  the  duct  from  without  to  steady  it  during  dissection  and 
indicate  its  situation  so  as  to  prevent  cutting  it.  The  distal  end  of  the  duct 
was  exposed  for  a  short  distance 
by  careful  dissection,  and  was  then 
passed  into  the  mouth  through 
a  small  incision  made  through  the 
buccal  mucous  membrane  and  con- 
fined there  with  horsehair  sutures. 
The  external  opening  was  refresh- 
ened and  closed  at  once. 

Richelofs  Method. — Richelot 
inserted  into  the  fistula  a  small  rubber  tube  so  as  to  cause  one  end  to 
project  slightly  into  the  mouth,  while  the  other  end  was  cut  off  obliquely 
and  so  placed  that  the  saliva  could  flow  directly  into  the  tube  (Fig.  732). 
Thereafter  the  external  wound  healed  promptly. 

Dequise's  Method. — Dequise  made  a  puncture  through  the  fistula,  open- 
ing obliquely  backward  and  inward  to  the  inner  surface  of  the  cheek, 
and  passed  through  it  one  end  of  a  leaden  wire  (Fig.  733).  A  second 
puncture  was  then  made  through  the  same  external  opening,  but  directed 

obliquely  forward  to  the  inner 
surface,  through  which  the  other 
end  of  the  wire  was  passed  into 
the  mouth  and  united  snugly  with 
its  fellow  by  twisting.  The  parotid 
secretion  promptly  followed  the 
leaden  guides  into  the  mouth, 
and  the  external  opening  quickly 
healed. 

Excision  of  the  Tonsil. — The  excision  of  the  tonsil  can  be  done  with  an 
ordinary  bistoury  or  with  curved  scissors,  aided  by  a  tenaculum.  The 
various  forms  of  tonsillotomes,  while  they  simplify  the  operation  by  giving 
the  operator  a  perfect  control  over  the  cutting  edge,  are  not  necessary  to  its 
execution. 

The  Removal  of  the  Ton.nl  tvith  the  Knife  or  Sri.'<.sors. — If  the  patient  be 
young  or  unable  to  exercise  self-control,  give  an  anaesthetic,  or  apply  to  the 
tonsil  a  strong  solution  of  cocaine.  Cause  a  bright  light  to  shine  into  the 
open  mouth;  depress  the  tongue;  seize  the  tonsil  with  the  tenaculum  or 
forceps,  draw  it  inward  from  between  the  pillars  of  the  fauces,  and  with 
scissors  curved  on  the  flat,  or  with  the  probe-pointed  bistoury,  or  an  ordi- 
nary bistoury  with  the  point  guarded  by  adhesive  plaster,  sever  the  tonsil 
from  below  upward.  It  is  not  necessary  at  first  to  remove  the  entire  tonsil, 
since  a  curative  influence  is  often  established  by  an  incomplete  removal. 


Fig.  733. 


qmse 


OI'KlJA'l'IONS   ON   THE    MOl'l'lI.  rjj;.- 

Amon;^  the  tonsillotomcs  in  common  iiso  iiro  MathiL'u's  and  Mackenzie's.  In 
iisin^  the  instrument  the  patient  is  phu^ed  as  hefore  stated,  and  the  ring  of 
the  instrument  is  adjusted  around  the  tonsil  witli  the  aid  of  the  index 
linj^er;  the  tonsil  is  elevated  by  a  teiuiculum,  or  by  a  special  hook  of  the 
instrument,  and  severed  by  pressing  the  blade  against  it. 

The  Ih'suJts. — Any  undue  luemorrhage  can  be  controlled  by  ice,  pres- 
sure, and  astringents;  actual  cautery  is  rarely  needed.  In  four  instances 
the  internal  carotid  artery  has  been  wounded  by  recklessness  in  cutting  the 
tonsils. 

Abscess  of  the  Tonsil. — In  opening  abscesses  of  tlie  tonsil  and  of  the 
fauces  great  care  should  be  exercised  not  to  invade  the  tissue  too  deeply  and 
endanger  the  internal  carotid.  Therefore,  attention  to  the  anatomy  of  the 
tonsil  and  its  environments  is  important  (i)iige  575).  The  blade  of  a  scalpel, 
well  guarded,  except  at  the  })oint,  with  adhesive  plaster  or  with  sterilized 
gauze,  is  often  employed  for  making  the  incision  (Fig.  734,  (j). 

Oi'KU.VTIONS   ON    THE    TONGUE. 

It  is  often  necessary  to  remove  the  tongue  in  part  or  entirely  on  ac- 
count of  hypertrophy  and  malignant  or  other  growths  of  its  structure. 
The  elements  of  danger  in  removal  of  the  tongue  relate  to  hjx^morrhage, 
which  is  increased  by  the  difficulty  in  catching  the  bleeding  points,  and  to 
the  danger  of  blood  entering  the  larynx,  both  of  which  are  emphasized  by 
loss  of  command  of  the  patient.  The  arteries  supplying  the  organ  are  the 
dorsalis  lingua?,  ranine,  and  branches  from  the  ascending  pharyngeal.  The 
ranine,  the  principal  branch,  runs  along  the  under  surface  of  the  tongue 
from  the  base  to  the  apex.  The  facial  and  sublingual  arteries  are  not 
endangered  unless  the  floor  of  the  mouth  is  operated  on  in  conjunction 
with  the  tongue.  It  should  be  remembered  that  the  vessels  on  either  side  of 
the  organ  do  not  often  communicate  freely  with  each  other,  and  consequently 
ligaturing  of  the  lingual  artery  of  one  side  will  permit  of  free  incision  on 
that  side  with  but  trifling  h;\?morrhage.  The  buccal,  sublingual,  and  sub- 
maxillary glands  are  closely  associated  with  this  organ  in  a  surgical  sense. 

The  principal  danger  from  bleeding  arises  from  division  of  the  lingual 
arteries.  The  situation  of  the  hemorrhage  is  much  more  disturbing  than 
the  amount.  Similar  sized  vessels  divided  elsewhere  in  the  body  would 
scarcely  cause  the  least  apprehension.  Bleeding,  however,  can  be  prevented 
by  ligature  of  these  vessels  in  the  neck  (Fig.  218)*,  or  controlled  for  the  time 
being  by  firm  pressure  upward  on  the  floor  of  the  mouth  by  the  thumbs  of 
an  assistant,  together  with  drawing  the  base  of  the  tongue  forward  by  means 
of  the  finger  hooked  over  it.  Is'ot  only  do  these  manipulations  control 
haemorrhage,  but  also  fix  the  floor  of  the  mouth  so  that  the  bleeding  points 
can  be  better  seen  and  more  quickly  caught. 

A  metltod  has  been  recommended  by  Langenbeck  to  control  the  haemor- 
rhage when  but  half  or  two  thirds  of  the  anterior  portion  of  the  tongue  is  to 
be  removed  by  cutting. 

A  long,  well-curved  needle,  armed  with  a  strong  ligature,  is  entered  at 
the  left  of  the  median  line  of  the  tongue,  behind  the  portion  to  be  removed, 


566  OPERATIVE  SURGERY. 

and  passed  through  to  the  right  side  and  under  surface  of  tlie  organ,  so  as 
to  carry  the  Hgature  beneath  the  branches  of  the  lingual  artery  at  this  situ- 
ation. The  ligature  is  then  carried  through  the  right  border  of  the  tongue 
and  firmly  tied.  A  similar  procedure  is  repeated  on  the  opposite  side  of  the 
tongue.  These  ligatures  can  be  used  also  to  draw  the  tongue  forward  during 
operation.  The  late  Dr.  Howe,  of  this  city,  devised  a  "  safety-pin  clamp  " 
with  which  he  j^roposed  to  control  the  haemorrhage  by  passing  the  pin  above 
the  arteries  and  screwing  the  clamp  into  position  against  the  intervening 
tissues. 

The  danger  of  blood  entering  the  air  passages  can  be  obviated  by 
turning  the  head  forward  and  to  one  side.  In  fact,  when  the  head  is  thus 
placed,  and  the  mouth  widely  opened,  the  arterial  jets  will  escape  through 
the  latter,  and  thus  reduce  the  active  bleeding  in  the  mouth  to  a  minimum. 
The  important  desiderata  are  having  the  patient  and  the  tongue  under 
complete  control,  the  dangers  from  haemorrhage  are  then  insignificant. 

Preliminary  Laryngotomy. — Preliminary  opening  of  the  larynx  or  trachea, 
together  with  tamponing  of  the  pharynx,  are  wise  measures  in  those  instances 
in  which  careful,  deliberate,  and  uuobscured  division  of  the  tissues  is  needed 
for  the  purpose  of  suitable  removal  of  the  disease.  In  extended  removal  of 
the  tongue  and  in  operation  on  the  floor  of  the  mouth  these  measures  find 
their  greatest  use.  If  there  be  no  fear  of  infection  at  the  seat  of  the 
operation,  the  tube  may  be  removed  as  soon  as  the  procedure  is  comjileted. 
Otherwise  it  should  remain  until  healthy  repair  is  established.  In  tampon- 
ing the  pharynx  with  a  sponge,  or  by  other  means,  to  prevent  the  entrance 
of  blood,  the  tongue  should  be  drawn  well  forward  at  the  time  of  introduction 
so  as  to  permit  complete  closure  of  the  pharynx  without  interfering  with 
the  necessary  manipulation  of  the  organ  for  the  arrest  of  haemorrhage,  etc. 

Before  operation,  the  mouth,  the  growth,  and  the  teeth  of  the  patient 
should  be  repeatedly  and  thoroughly  cleaned  by  the  frequent  and  free  use  of 
an  antiseptic  solution.  Irregular  and  loosened  teeth  and  dental  asperities 
should  be  removed  at  the  time  of  operation,  and  every  care  should  be 
taken  to  provide  for  the  operation  field  aseptic  cleanliness. 

Excision  of  the  Tongue. — The  tongue  may  be  removed  with  the  knife, 
scissors,  galvanic  cautery,  ecraseur,  or  ligature.  The  last  method  and  the 
galvanic  cautery  method  should  be  excluded,  as  the  greater  length  of  time 
required  and  the  greater  pain  caused  by  the  latter,  and  the  greater  dangers 
from  haemorrhage  and  from  sepsis  of  the  former,  unfit  them  for  use.  If  the 
diseased  portion  be  small,  it  may  be  taken  away  by  the  incision  best  calculated 
to  accomplish  the  object,  since  it  is  a  bad  plan  to  secure  symmetry  at  the  ex- 
pense of  future  safety.  If  hypertrophy  involve  the  npex,  or  if  a  tumor  he 
located  at  this  situation,  either  condition  can  be  treated  by  removing  a  V- 
shaped  piece  in  the  following  manner : 

The  Operation.  V-shaped  Incision. — Ansesthetize  the  patient;  place  him 
in  a  suitable  position  in  a  strong  light  with  the  mouth  well  opened  by  a 
special  gag,  or  any  proper  instrument,  forced,  with  a  string  attached,  between 
the  posterior  molars.  If  the  patient  be  in  the  recumbent  posture  turn  the 
head  to  one  side,  so  as  to  collect  the  blood  in  the  hollow  of  the  cheek ;  pass 


Kio.  734. — Instruments  employed  in  operations  on  the  tongue,  tonsil,  and  pillars  of  the 

fauces. 

a.  For  retraction  of  cheek.  6.  Tongue  forceps,  c.  Mouth  gag.  (/.Tenaculum,  e.  Curved 
and  blunt-pointed  scissors.  /.  Volselia.  g.  Bistoury  guarded  with  adhesive  plaster. 
h.  Sponge  forceps,  i.  Bone  drill.  A-.  Trachea  tube.  /.  Traction  loops,  in.  l!are-li{i 
pins.  n.  Stout  wire,  o  and  p.  Curved  and  straight  bone-cutting  forceps.  Scaljiels, 
forci pressure,  ligatures,  wipers,  etc.,  should  be  had  in  abundance. 


568 


OPERATIVE  SURGERY. 


a  stout  ligature  through  each  side  of  the  tongue,  just  outside  of  the  intended 
site  of  the  apex  of  the  V  incision ;  then  loop  the  ligatures  and  give  each  to 
an  assistant  with  instructions  to  pull  the  tongue  forward  ;  seize  the  tip  of  the 
tongue  with  a  forceps,  or  with  the  thumb  and  finger,  and  with  a  sharp- 
pointed,  narrow-bladed  knife  transfix  the  organ  posteriorly  from  below  up- 
ward in  the  median  line,  thus  locating  the  point  of  the  V,  and  cut  outward 


Fig.  735. — Removal  of  V-shaped  piece. 


Flaps  united. 


and  forward  through  one  border  of  the  tongue.  Check  the  points  of  severe 
hemorrhage  with  forceps ;  make  the  division  on  the  opposite  side  in  a  re- 
verse direction  from  the  border — backward — to  join  the  site  of  commence- 
ment of  the  first  incision  (Fig.  735).  Ligature  the  bleeding  points  and  unite 
the  flaps  by  sutures  in  the  usual  manner  (Fig.  736). 

Hypertrophy  of  the  Tongue  (Fig.   737). — Hypertrophy  of  the  tongue 
involving  its  entire  structure,  can  be  treated  by  the  removal  of  a  V-shaped 

piece  in  the  manner  just  described,  thus 
shortening  the  transverse  diameter  and 
diminishing  the  length.  The  flaps  are 
then  united,  and,  after  union  has  taken 
place,  the  thickness  of  the  tongue  can  be 
diminished  in  the  following  manner :  A 
strong  ligature  is  passed  laterally  through 
the  organ  near  to  the  base,  by  which  the 
tongue  is  drawn  forward  and  held,  while 
a  wedge-shaped  piece  is  removed  by  lat- 
eral transfixion  in  a  longitudinal  direc- 
tion, began  midway  between  the  upper  and 
lower  surfaces  of  the  organ  as  far  back  as 
possible.  The  under  flap  is  made  by  cut- 
ting downward,  outward,  and  forward 
through  the  under  surface  of  the  tongue; 
Fig.  737.— Hypertrophy  of  the  tongue,    the  upper  by  division  of  the  tissue  above 

the    last    incision.      The  bleeding    points 
should  be  ligatured  and  the  flaps  united  with  sutures. 

Half  of  the  organ  can  be  removed  througli  the  mouth  by  first  ligaturing 
the  lingual  artery  corresponding  to  the  side  of  operation,  after  which  two 


OI'KKATIONS   OX   'I'lIK    MoCTIF.  5(;<) 

lon<j;,  stout  lii^atiiics  iuh-  pusstd  llii<)iij,'h  tlu-  1(Mi;,'ui'  near  tliu  lip,  one  on  each 
side  of  ilie  iiu'dia?!  line,  l»y  means  of  which  the  tongue  is  drawn  forward  and 
upwaril  ;  the  freiiiiin  and  the  mucous  meml)raiie  lieneath  the  ton;,Mie  are  cut 
witli  scissors  back  to  the  base  of  the  organ  ;  tlie  tongue  is  then  divided  in 
half  from  before  backward  witli  a  knife  or  scissors;  its  deeper  tissues  are 
separated  by  tearing  with  the  Ihiger  or  the  handle  of  the  knife,  and  the  por- 
tion to  bo  removed  is  finally  severed  with  scissors.  The  remaining  half  can 
be  removed  in  a  similar  manner. 

The  Comments. — The  contention  on  the  part  of  some  surgeons  that  the 
entire  tongue  should  be  excised  when  removal  of  half  of  the  organ  appears 
needful,  has  many  strong  and,  it  seems  to  me,  wise  objections  offered  to  the 
j)ractice.  Half  of  the  tongue,  although  deformed  by  healing,  still  has  re- 
maining, in  a  crij)pled  state,  the  functions  that  characterize  the  organ  in 
health,  such  as  sj)eaking,  swallowing,  tasting,  etc.  The  moral  effect  on  the 
patient  of  a  proi)osition  to  renu)ve  the  entire  organ  at  the  outset  will  too 
often  lead  to  a  rejection  of  tiie  operation,  thereby  causing  delay  which 
may  render  unserviceable  any  operative  procedure.  Fiiudly,  if  removal  of 
but  half  of  the  organ  alTords  only  temporary  respite,  the  remainder  can  then 
be  taken  away  with  uo  greater  danger  than  that  attending  the  removal  of  the 
whole  in  the  first  instance.  Hueter  suggests  that,  in  excision  of  the  anterior 
portion  of  one  side  of  the  tongue,  the  gap  be  closed  at  once  by  using  as  a 
flap  for  that  purpose  the  apex  of  the  remaining  portion.  The  advantages 
that  may  follow  this  practice  are  measured  by  the  comparative  differences 
resulting  from  prompt  union  with  a  shortened  organ  and  those  of  one 
crippled  by  the  cicatricial  influences  of  prolonged  healing.  Ilueter's  sugges- 
tion in  this  regard  is  not  often  followed. 

The  Removal  of  the  Entire  Tongue. — The  removal  of  the  entire  tongue 
can  be  done  through  the  mouth,  beneath  the  inferior  maxilla,  by  division 
at  the  lower  jaw  either  at  the  symphysis  or  at  one  side  of  it,  or  through 
the  cheek.  It  can  be  removed  through  the  mouth  by  means  of  the  knife, 
the  scissors,  the  galvano-cautery,  (?)  and  the  ecrasenr. 

The  Operation  through  the  Mouth. — Put  the  patient  thoroughly  under 
the  influence  of  an  anaesthetic  at  the  outset,  as  afterward  only  partial  in- 
sensibility is  desired  ;  gag  the  mouth,  and  support  the  head  so  that  the  blood 
will  escape  externally  rather  than  into  the  pharynx.  Pass  a  stout  thread 
through  the  tongue  at  the  juncture  of  the  middle  and  anterior  thirds  ;  draw 
the  organ  forward  and  upward  with  the  thread,  and  detach  it  with  scissors 
from  its  connections  with  the  jaw  and  anterior  pillars  of  the  fauces ;  divide 
the  muscles  of  the  tongue  with  strong,  straight,  blunt-ended  scissors  back  to 
near  the  larynx,  as  closely  to  the  under  surface  as  the  disease  will  permit. 
The  glosso-epiglottidean  folds  are  now  brought  under  control  by  passing  a 
long  ligature  through  each  fold.  These  ligatures  are  allowed  to  remain  in 
situ  in  order  that  the  floor  of  the  mouth  may  be  drawn  forward  by  them 
in  the  event  of  secondary  haemorrhage  or  difficult  respiration.  The  excision 
is  then  completed  and  all  bleeding  points  are  checked. 

The  Comments. — The  fra?num  linguae  and  the  anterior  pillars  of  the  fauces 
should  be  completely  and  promptly  divided  so  as  to  permit  a  free  withdrawal 


570 


OPERATIVE  SURGERY. 


Fig. 


r38. — a.  Jaeger's  inei^^ioll. 
er's  incision. 


b.  Koch- 


of  the  tongue  from  the  mouth.  Whitehead  advises  that  the  muscles  of  the 
tongue  be  rapidly  and  boldly  cut,  irrespective  of  other  than  arterial  haemor- 
rhage, as  the  oozing  will  be  promptly  checked  by  control  of  the  various 
arteries.  With  previous  study  and  present  caution  these  arteries  can  be 
caught  and  tied  or  twisted  before  being  severed,  after  which  the  operation 
is  promptly  completed  without  further  troublesome  hemorrhage.  A  pre- 
liminary tracheotomy  is  advisable  in  those  cases  in  which  extensive  wound 

surfaces  and  troublesome  haemorrhage 
are  anticipated.  Infective  pneumonia 
is  obviated  in  the  former,  and  the  en- 
trance of  blood  to  the  pharynx  is  pre- 
vented in  the  latter  instance. 

The  ligaturing  of  the  lingual  arteries 
beneath  the  hyoglossus  muscles  before 
the  employment  of  the  scissors  for 
removal  of  the  tongue  simplifies  the 
operation  exceedingly,  as  then  the  dan- 
gers and  annoyance  of  present  or  pros- 
pective hai^morrhage  are  largely  obvi- 
ated. Now  and  then  a  dorsal  lingual 
branch  requires  attention.  The  author 
has,  however,  noted  but  one  instance 
of  this  kind  in  his  own  practice.  Xor 
is  this  all,  for  the  ligature  of  these  ves- 
sels affords  opportunity  for  the  removal  of  the  lymph  glands  associated 
directly  with  the  affected  part  of  the  tongue,  whether  they  are  diseased  or 
not,  a  measure  of  far  greater  importance  in  our  opinion  than  that  of  liga- 
ture of  the  vessels.  In  fact  it  is  our  practice,  and  we  believe  that  it  should 
be  made  the  first  step  of  operative  endeavor,  to  remove  these  glands,  tying 
the  lingual  or  not  as  may  then  seem  wise. 

The  After-treatment.— Wash  the  floor  of  the  mouth  cautiously  with  a  solu- 
tion of  biniodide  of  mercury  (1  to  1,000),  dry  it,  and,  if  desirable,  paint  the  raw 
surface  with  the  antiseptic  varnish  of  Whitehead,  which  is  compounded  by 
substituting  for  the  rectified  spirits  in  the  compound  tincture  of  benzoin  a 
mixture  of  nine  parts  of  ether  and  one  of  turpentine  saturated  with  iodo- 
form. Before  using  the  ether  add  one  part  of  turpentine  to  ten  of  that  fluid. 
The  mixture  dries  quickly  and  remains  as  a  firm  coating  for  twenty-four 
hours.  Gauze  packings  are  regarded  as  objectionable  by  some,  as  they  be- 
come quickly  saturated  with  saliva.  Treves  makes  "  no  applications  of  any 
kind  "  other  than  antiseptic  solutions. 

Kocher's  Method.— Kochav  recommends  the  following  plan  if  the  floor  of 
the  mouth  and  contiguous  glands,  and  even  the  pharynx  be  involved  along 
w\th  the  tongue :  After  a  preliminary  laryngo-tracheotomy  and  thorough 
cleansing  of  the  parts,  a  triangular  flap  is  made,  with  the  base  upward,  its 
lower  boundaries  corresponding  to  the  course  of  the  digastric  muscle,  and 
its  apex  being  at  the  point  of  connection  of  this  muscle  with  the  hyoid 
bone  (Fig.  738,  h).     The  posterior  incision  may  also  be  made  from  the  apex 


OPERATIONS  ON   TIIK    .MolJ'Jll. 


571 


directly  to  the  anterior  bcjnlur  of  the  steriKi-inustoicl  miisele,  thence  up- 
wiird  along  this  border  to  the  angle  of  the  jaw,  thus  affording  a  greater 
space  than  is  .socnretl  by  the  former  line  of  incision.  This  llap  covers  tlie 
region  of  the  jaw  and  neck  occupied  by  the  facial  artery  and  the  subnmxillarv 
glands  posteriorly,  and  the  lingual  artery  and  the  sublingual  glands  anteriorly. 
The  llap  is  dissected  up,  the  arteries  are  tied,  and  the  glands  are  removed. 
This  exposes  the  side  of  the  base  of  the  tongue  and  the  back  part  of  the  lloor 
of  the  mouth  to  easy  inspection  and  manipulation.  The  larynx  and  pharynx 
are  then  protected  from  the  entrance  of  blood  by  a  large  sponge,  to  which  a 
string  should  be  attached,  and  the  myo-hyoid  muscle  is  divided  close  to  the 
jaw,  exposing  the  tongue  and  mouth  freely.  The  orgati  is  now  drawn  through 
the  opening,  split,  and  the  half  of  it  on  the  side  corresponding  to  the  flap  is 
removed,  including,  if  necessary,  the  floor  of  the  mouth,  pillars  of  the  fauces, 
and  pharynx,  down  to  tlie  hyoid  bone.  The  remaining  portion  can  be  re- 
moved in  a  similar  manner  through  a  triangular  opening  on  the  opposite 
side  or  through  the  primary  opening,  if  the  extent  of  the  disease  will  permit. 
As  before  remarked,  the  operation  whicli  involves  the  bone  and  soft  parts 
around  it  results  less  favorably  than  when  the  tongue  is  removed  through 
the  mouth  by  the  methods  described. 

The  Comments. — The  lingual  artery  at  either  side  may  be  tied  before  the 
flaps  are  turned  up,  or  they  may  be  ligatured  afterward,  as  suits  the  desire 
of  the  surgeon.  If  the  entire  tongue  be  removed  at  one  side,  the  lingual 
artery  of  the  opposite  side  should  be  tied  before  the  removal. 

The  After-treatment  consists  in  keeping  the  mouth  well  cleansed,  while 
to  the  raw  surfaces  iodoform  and  iodoform  gauze  or  other  suitable  anti- 
septic dressings  are  applied.     The  tracheotomy  tube  should  not  be  removed 
until  all  dangers  from  inflammation  and  from 
infective  pneumonia  due  to  the  discharges  are 
ended. 

The  Removal  of  the  Tongue  with  Division 
of  the  Jaw  does  not  offer  the  chances  of  success 
secured  by  the  preceding  method. 

ScdiUofs  Method. — Beginning  at  the  median 
line  of  the  lower  lip,  divide  the  soft  parts  verti- 
cally downward  to  the  hyoid  bone  (Fig.  739,  a) ; 
extract  a  central  incisor  tooth  and  drill  a  small     /'' 
hole  through  the  body  of  the  lower  jaw  at  either   Ym.  T.VJ.—a.  Incision  of  Si'dil- 

side,  a  quarter  of  an  inch  from  the  median  line ;  ^'^^' .^^°"-'^•.  ^.'*''"<'-  ^^-  ^fP- 
,..,,,       .        .       ,,  ,.        ,.  ,.     „  noli  s  incision,     c.   Billroth  s 

divide  the  jaw  in  the  median  line  vertically  or        incision. 

irregularly — the  latter  affords  opportunity  for  a 

more  substantial  subsequent  coaptation ;  pass  a  strong  ligature  through  the 

tongue  and  separate  the  bony  fragments,  thus  exposing  to  view  the  floor  of 

the  mouth.     Divide  the  mucous  membrane  at  its  connection  with  the  jaw, 

also  the  genio-hyoid  and  genio-hyoglossi  muscles;  draw  the  tongue  forward 

and  sever  the  remaining  attachments  carefully  with  scissors,  securing  the 

ranine  vessels  before  their  division.     The  tongue  may  be  either  removed 

entire  or  split  and  each  half  removed  separately,  as  before  described.     Unite 


572 


OPERATIVE   SURGERY. 


the  jaw  with  silver  wire ;  drain  the  wound  from  the  lower  angle ;  fortify  the 
line  of  junction  of  the  jaw  with  an  interdental  splint  (Fig.  743) ;  unite  the 
stump  of  the  tongue  to  the  sides  of  the  mouth  and  maintain  thorough  clean- 
liness by  the  frequent  employment  of  antiseptic  solutions. 

Jaeger'' s  Method. — Jaeger  divided  the  cheek,  from  the  angle  of  the  mouth 
back  to  the  anterior  border  of  the  masseter  muscle  (Fig.  738,  a),  and  ap- 
proached the  diseased  tongue  in  this  manner.  This  measure  is  serviceable 
in  instances  in  which  the  disease  is  located  far  back  on  the  tongue,  and  in 
which  the  anterior  pillar  of  the  fauces  is  invaded,  also  in  the  event  of 
inefficient  light,  severe  haemorrhage,  an  uncontrollable  patient,  or  a  limited 
separation  of  the  jaws.  If  scarring  be  of  special  significance,  other  means  of 
attainment  of  the  objects  should  be  considered. 

The  employment  of  the  ecraseur\  as  practiced  by  Mr.  Baker,  is  a  satis- 
factory means  of  removing  the  tongue. 

BaTcers  Method  (Ecraseur). — Pass  through  each  side  of  the  tongue,  one 
inch  from  the  extremity  and  half  an  inch  from  the  median  line,  a  strong 
silk  ligature,  which  is  firmly  tied  and  looped  ;  the  operator,  holding  one  loop 
while  the  assistant  holds  the  other,  causes  the  tongue  to  be  drawn  forward, 

and  then  with  a  blunt-pointed  scalpel, 
aided  by  the  fingers,  splits  the  tongue 
in  the  median  line  back  to  a  point  one 
inch  behind  the  cancerous  growth ; 
arrest  haemorrhage,  draw  the  diseased 
half  still  farther  forward,  sever  the 
muscular  and  mucous  connections  at 
the  symphysis,  and  with  sharp-pointed 
scissors  divide  the  mucous  membrane 
backward  along  the  lower  jaw  to  one 
inch  behind  the  site  of  the  growth. 
Free  the  diseased  portion  of  the  organ 
from  its  attachments  so  as  to  readily 
permit  the  application  of  the  ecraseur 
and  the  division  of  the  segment  at  a 
point  as  far  as  possible  from  the  growth; 
pass  two  strong,  blunt-pointed  curved 
needles  through  the  tongue  far  behind  the  seat  of  the  disease,  and  adjust  the 
loop  of  the  ecraseur  around  the  segment  behind  and  below  them,  so  as  to 
cause  it  to  pass  wide  of  the  disease  at  the  line  of  severance.  Baker  em- 
ployed a  whipcord  loop  (Fig.  740)  with  a  moderate-sized  instrument,  curved 
somewhat  on  the  flat  at  the  lower  end.  Vessels  which  may  remain  unsevered 
after  tightening  the  loop  are  ligatured  and  divided,  and  the  nerves  are  sev- 
ered close  to  the  stump.  If  necessary,  the  remaining  half  of  the  tongue  is 
treated  in  a  similar  manner.  The  instrument  can  be  applied  to  the  tongue 
through  an  opening  made  behind  the  symphysis,  if  the  surgeon  chooses, 
although  with  no  practical  advantage. 

The  Precautions. — As  the  loop  is  tightened  around  the  tongue,  care 
must  be  observed  to  prevent  it  from  slipping  forward  nearer  to  the  seat  of 


Fig.  740. — Whipcord  loop  applied. 


OPERATIONS   ON    TIIK    MolTH. 


r:j 


tho  diseusi!,  which  is  liiil)lo  to  luipjKJii  iioLvviihsUiiKiiii^  the  restruiniu<^  inllu- 
etices  of  the  tnmsfixion  needles  and  of  the  shiiUovv  grooves  made  in  the  soft 
parts  for  the  h)dgment  of  tlie  loop.  Sinee  tiie  nerve  and  the  vessels  often 
escape  the  ellect  of  the  loo]),  the  loop  should  be  withdrawn  carefully,  the 
nervo  cut,  and  the  artery  caught  and  tied  to  avoid  embarrassing  haemorrhage. 

Iicgnuirs  Mclliod. — The  operation  devised  l)y  Kegnoli  alT(»rds  easy  access 
to  all  portions  of  the  tongue,  except  its  base,  and  also  furnishes  good  drain- 
age, but  creates  a  large  and  somewhat  dangerous  wound. 

The  Operation. — An  angular  or  crescent-shaped  incision  is  carried 
along  the  base  of  the  lower  jaw  (Fig.  739,  b)  extending  between  the  anterior 
borders  of  the  masseter  muscles,  avoiding  the  facial  arteries.  A  vertical 
incision  is  then  made  from  the  center  of  this  to  the  median  line  of  the 
hyoid  bone.  The  flaps  are  reflected,  the  mucous  membrane,  the  attachments 
of  the  lingual,  hyoid,  and  digastric  muscles  divided  from  the  inner  surface 
of  the  lower  jaw,  and  the  tongue  is  freed  laterally  from  the  anterior  pillars 
as  in  other  methods.  The  tongue  is  then  drawn  through  the  opening  and 
severed  by  the  knife  or  scissors,  the  bleeding  points  being  secured  as  fast  as 
they  appear.  The  Haps  are  united,  the  wound  is  drained,  and  the  remaining 
raw  surfaces  are  allowed  to  heal  by  granulation. 

Billroth  made  a  somewhat  curved  submental  incision  (Fig.  739,  c)  only, 
and  extended  it  at  either  side  so  as  to  permit  ligature  of  the  lingual  arteries 
and  removal  of  the  infected  glands 
before  extirpation  of  the  tongue  (Fig. 
741). 


Fig.  741. — Tongue  exposed  tlirough 
BiUroth's  submental  incision. 


Fio.  743.- 


-Langenbeck's  incision. 
mouth  involved. 


Floor  of 


If  the  floor  of  the  mouth  were  involved  in  addition  to  the  tongue,  Billroth 
made  an  incision  about  one  inch  below  the  border  of  the  lower  lip,  from 
one  facial  artery  to  the  other;  at  either  end  of  this  incision  he  made  a 
vertical  one  extending  downward  to  a  point  about  four  fifths  of  an  inch 
below  the  lower  border  of  the  inferior  maxilla ;  at  the  sites  of  juncture  of 
these  vertical  incisions  with  the  jaw  he  divided  the  bone  and  turned  it 
downward  along  with  the  soft  parts,  thereby  affording  ample  room  to  reach 
the  diseased  parts  within.  After  extirpation  of  the  disease,  he  wired  the  frag- 
ments in  position  and  closed  the  wound.    Langenbeck  (Fig.  74^)  divided  the 


574  OPERATIVE  SURGERY. 

jaw  on  the  side  of  the  greatest  amount  of  disease,  drew  apart  the  fragments, 
excised  the  tongue,  floor  of  the  mouth,  etc.  Tiie  jaw  was  united  as  in  the 
preceding  instance.  If  tlie  portion  to  be  removed  be  extensive  and  the 
danger  from  haemorrhage  great,  a  preliminary  tracheotomy  is  advisable. 
This  measure  not  alone  prevents  the  blood  from  obstructing  respiration, 
but  lessens  the  dyspnoea  frequently  caused  by  a  wide  separation  of  the  jaws. 
The  Choice  of  Method, — In  the  choice  of  method  Treves  wisely  presents 
the  following  propositions : 

"  1.  The  organ  should  be  removed  by  cutting  either  with  scissors  or  with 
the  bistoury. 

"  2.  The  removal  should,  as  a  general  rule,  be  effected  through  the  mouth. 
(Simple  removal  in  202  cases,  of  whole  or  part  of  organ,  1-4  died  (Butlin).) 

"  ;i  Every  means  should  be  taken  to  reduce  the  haemorrhage  to  a  mini- 
mum. 

"4.  When  the  floor  of  the  mouth  is  involved,  or  the  glands  are  exten- 
sively diseased,  the  excision  should  be  carried  out  through  the  neck." 

The  General  Remarks. — Cancer  of  the  tongue  causes  infection  of  lymph 
glands  speedily,  and  prompt  action  should  be  counseled  in  all  instances. 
Therefore,  an  accurate  knowledge  of  the  nature  of  a  morbid  growth 
of  the  tongue  should  be  quickly  gained,  and,  too,  before  the  employment 
of  irritating  applications.     When  the  disease  is  located  at  the  fraenum  it 

is  difficult  of  removal  and  of  proper  esti- 
mation of  the  extent  without  first  ex- 
tracting two  or  three  of  the  lower  incisor 
teeth.  A  suitable  vulcanite  interdental 
splint  constructed  to  fit  the  jaw  before  its 
division  is  the  best  agent  for  the  retention 
in  place  of  the  fragments  after  operation 
(Fig.  743).     It  should  not  be  overlooked 

that  in  hopeless  cases  the  removal  of  the 
Fig.     743.  —  Kingsley's    interdental      t  e  iu     i,  i         •>.  xi.         u 

splint  of  vulcanized  rubber.  ^l^sease  from  the  buccal  cavity,  even  though 

it  returns  promptly  elsewhere,  rescues  the 

patient  from  the  pitiless  suffering  attendant  on   its  presence  in  the  mouth. 

The  After-treatment. — Thorough  asepsis  and  a  liberal  nutritious  diet 
are  the  elements  of  prime  significance  in  the  treatment.  Rectal  alimenta- 
tion for  the  first  two  days,  followed  by  the  use  of  the  stomach  tube,  if  neces- 
sary, is  very  important.  Abundant  fresh  air  and  cleanliness  of  the  mouth 
should  be  secured. 

Tlie  Results. — The  rate  of  mortality  from  removal  of  the  tongue  by  all 
of  the  methods  described  is  considerable,  fifty-six  out  of  two  hundred  and 
forty-four  cases  having  died.  In  one  hundred  and  sixty-three  cases  of  re- 
moval through  the  mouth  attended  with  preliminary  ligature  of  the  Unguals 
only,  the  death-rate  was  12.8  per  cent.  In  fifty-eight  cases  operated  on  by 
Kocher,  the  death-rate  was  about  10.5  per  cent.  In  twelve  cases  done  by 
Kocher  after  his  own  method  the  death-rate  was  8.3  per  cent.  In  removal 
requiring  excision  of  the  jaw  or  extensive  dissections,  the  rate  is  increased 
five  and    ten  per   cent.      In  two    hundred  and    forty  cases    ten    per  cent 


OPKRATIONS   ON    TllH    MoL  Til. 


575 


reached  the  three-year  luid  G.(i  per  cent  the  four-year  limit.  In  severe  cjises, 
when  thoroughly  doiu-,  the  life  limit  is  eneouragin«^,  us  is  shown  by  the  fact 
that  half  of  Koeher's  long-livi-d  ones  were  of  this  character.  Whitehead 
reports  1"^'.)  eases,  in  whieh,  so  far  as  could  be  known,  8  lived  from  '.i  to  10 
years,  17  succumbing  before  the  three-year  jjcriod  ((hirtis).  'i'reves  reports 
34  cases  of  his  own  attended  with  j)rimary  ligature  of  the  Unguals,  in  which 
'.)  died,  liaker  reports,  as  the  result  of  his  method,  40  cases  with  5  deaths, 
1  from  diphtheria.  Many  of  Whitehead's  cases  are  early  ones.  The  rate  in 
removal  of  glands  and  part  or  whole  of  tongue  below  jaw  is  5  per  cent  better 
than  with  division  of  jaw. 

Tongue-tie. — Tongue-tie  depends  on  an  undue  extension  forward,  either 
with  or  without  an  abnormal  shortening  of  the  frjcnuni  linguae.  If  the 
condition  be  severe  enough  to  call  for  treatment,  the  end  of  the  tongue  is 
pressed  upward  by  passing  the  first  two  fingers  beneath  it,  palm  downward, 
bringing  the  tense  fra^uum  between  them,  which  can  be  divided  with  a  blunt- 
pointed  scissors  at  a  little  distance  from,  but 
parallel  with  the  palmar  surface,  care  being 
taken  not  to  sever  the  ranine  artery. 

Ranula  (Fig.  744).— The  closure  of  the 
ducts  of  the  sublingual  and  other  glands  in 
this  situation  causes  a  cystic  distention  of 
them,  and  even  of  the  glands  themselves.  If 
it  is  not  possible  to  find  and  probe  the  duct 
openings,  it  will  be  necessary  to  evacuate  the 
contents  at  the  floor  of  the  mouth  below  the 
tongue,  or,  if  the  tumor  be  of  large  size,  this 
must  be  done  in  the  median  line  externally, 
close  to  the  hyoid  bone.  In  either  instance 
it  may  be  necessary  to  pack  the  cavity  with 
lint  and  liquor  ferri  sulphatis,  or  cauterize 

the  sac  with  nitrate  of  silver  or  carbolic  acid,  and  even  to  dissect  it  partially 
or  entirely  away.  The  use  of  stimulating  injections,  the  introduction  of  a 
seton  of  silk  medicated  with  an  astringent  or  stimulant,  or  the  division  and 
stitching  outward  of  a  i)ortion  of  the  wall  of  the  cyst,  may  be  practiced  if 
simpler  means  fail. 

Removal  of  Tumor  of  Tonsil  and  Pillar  of  Fauces.— This  operation  is 
practiced  for  the  purpose  of  removal  of  malignant  disease  of  the  tonsil,  with 
or  without  involvement  of  contiguous  tissues.  In  the  simpler  forms  the 
disease  can  be  removed  through  the  mouth.  But  if  the  disease  be  exten- 
sive, and  evidences  of  deep  tissue  and  lymphatic  involvement  be  noted,  the 
approach  should  be  made  from  the  neck  (pharyngotomy).  In  either  in- 
stance a  careful  study  of  the  important  nervous  and  vascular  relations  to  the 
diseased  structure  should  be  made. 

The  Anatomical  Points.— The  tonsil  in  health  corresponds  to  the  angle  of 
the  lower  jaw.  It  is  a  vascular  structure  receiving  branches  from  the  facial, 
internal  maxillary,  lingual,  and  ascending  pharyngeal  arteries.  The  internal 
carotid  lies  at  the  outer  and  posterior  aspect  of  the  tonsil,  at  a  distance  of 


Fig.  744. — Ranula. 


576 


OPERATIVE  SURGERY. 


about  three  fourths  of  an  inch,  separated  from  it  by  the  muscular  and 
fibrous  structures  of  tlie  pharynx,  the  styloglossus,  and  stylopharyngeus 
muscles.  The  glosso-pharyngeal  nerve  has  a  substantially  similar  associa- 
tion. The  removal  of  the  tonsil  for  malignant  disease  can  be  carried 
ou  through  the  mouth  or  through  an  incision  in  the  neck.  The  former 
route  is  advisable  when  the  growth  is  limited  to  the  tonsil,  and  even  extends 
to  the  base  of  the  tongue,  and  is  not  attended  with  glandular  involvement. 
In  some  instances  either  tracheotomy  with  pharyngeal  plugging,  or  splitting 
of  the  cheek,  and  ligature  of  the  external  carotid,  may  be  practiced,  especially 
the  latter,  if  for  no  other  reason  than  that  of  lessening,  for  a  time,  at  least, 
the  blood  supply  of  the  diseased  part. 

The  Operation. — Fix  the  mouth  widely  open  with  the  gag  and  raise  the 
shoulders  so  as  to  expose  the  parts  to  a  good  light ;  seize  the  diseased  tonsil 
with  forceps  or  tenaculum,  and  draw  it  well  into  the  mouth,  then  with  long, 
blunt-pointed  scissors  divide  the  tissues  cautiously  and  as  far  away  from 
the  growth  as  advisable,  arresting  haemorrhage  with  sponge  pressure,  tor- 
sion, etc.,  as  it  appears.  If  the  disease  has  extended  beyond  the  tonsil  to 
the  pillars  of  the  fauces,  divide  the  soft  palate  near  to  the  median  line, 
thence  outward  with  scissors,  and  finally  remove  the  pillars  of  the  fauces 
and  the  tonsil  by  means  of  blunt  dissection  carried  on  with  the  scissors, 
fingers,  or  an  instrument  devised  for  the  purpose.  If  it  so  happens  that  the 
large  size  of  the  growth  interferes  with  the  visual  or  manipulative  oppor- 
tunities of  the  surgeon,  the  growth  may  be  reduced  in  size  by  the  galvano- 
cautery  knife  at  a  dull  red  heat.  Forcipressure  and  sponge  pressure  usually 
meet  the  haemostatic  requirements. 

Pharyngotomy  (Cheever's  Method,  Fig.  745). — Make  an  incision  through 
the  integument,  platysma,  and  fascia  along  the  anterior  border  of  the  sterno- 
mastoid  muscle  from  the  level  of  the  lobe  of  the  ear 
to  below  the  level  of  the  tumor ;  make  a  second  one 
extending   from   the   first   along  the    body  of  the 
lower  jaw;  dissect  and  draw  aside  the  flaps;  avoid, 
if  possible,  the  lower  branches  of  the  facial  nerve ; 
divide  the  stylo-hyoid,  styloglossus,  stylo-pharyngeus, 
and  the  digastric  muscles,  if  need  be ;  ligature  and 
divide  the   facial  artery  and  vein;  draw  the  sub- 
maxillary gland  forward,  and  the  internal  jugular 
vein   and   carotid   arteries   outward,   exposing    the 
pharyngeal  wall.     Introduce  the  forefinger  into  the 
mouth  and  outline  the  extent  of  the  disease,  aided 
by  conjoined  manipulation  from  without.    Open  the 
pharynx  in  front  of  the  disease  from  without  with  a 
galvano-cantery  knife  or  with  scissors,  thence  passing 
incision.     — -.    Author's   upward,  backward,  and  downward,  circumscribing 
secondary  incision  to  a,  b.    ^^^^  ^y^^^^^^  widely  and  removing  it  along  with  the  con- 
tiguous portion  of  the  wall  of  the  pharynx,  leaving  no  lyinphatic  glands  behind. 
The  Remarks. — The  author,  in  a  recent  severe  case  requiring  excision  of 
the  ascending  ramus  of  the  jaw,  carried  the  first  («,  h)  incision  along  the  lower 


Fig.  745. — a,  b,  c.  Cheever's 
incision,     a,  c.  Mikulicz's 


OI'MKA  rio.NS   ON    TIIK    I'llAliVNX.  577 

bonU'i-  of  the  hori/oiital  ranius  of  tlio  jaw  instcjid  of  in  the  course  dcscriliccl 
above.  The  second  incision  (dotted  line)  was  made  backward  and  down- 
ward from  near  to  the  center  of  the  first,  and  the  <hij)8  were  reflected  in 
the  usual  manner.  On  closing  the  external  wound,  the  lower  end  of  the 
second  incision  was  situated  admirably  for  the  purposes  of  dependent 
drainage. 

Czvrnifs  MctJiod. —  Introduce  a  tracheotomy  tube,  and  tampon  the 
pharynx;  make  an  incision  from  the  angle  of  the  mouth  downward  and 
outward  to  the  anterior  border  of  the  masscter,  thence  downward  to  the  level 
of  the  hyoid  bone;  expose  and  divide  the  lower  jaw  just  in  front  of  the  last 
molar  tooth  ;  draw  the  fragments  apart  and  divide  the  buccinator,  digastric, 
styloglossus,  stylo-hyoid,  and  stylopharyngeus  muscles;  secure  the  facial  and 
lingual  vessels;  avoid  the  salivary  glands,  and  the  lingual,  hypoglossal,  and 
glosso-pliaryngeal  nerves.  After  removal  of  the  growth  the  jaw  is  united 
with  silver  wire,  and  the  wound  is  closed  and  dressed. 

Mikulicz's  Method. — Tracheotomy  and  pharyngeal  tampon  are  em- 
ployed the  same  as  before.  Make  an  incision  from  the  tip  of  the  mastoid 
})rocess  along  the  anterior  border  of  the  sterno-mastoid  muscle  to  the  greater 
cornu  of  the  hyoid  bone.  Expose  both  surfaces  of  the  ascending  ranius  of 
the  lower  jaw  with  the  rugine,  carefully  avoiding  the  parotid  gland,  facial 
vessels,  and  external  carotid  artery;  exsect  the  ramus,  draw  aside  with 
strong  hooks  the  body  of  the  jaw,  the  masseter,  internal  pterygoid,  digastric, 
and  stylo-hyoid  muscles,  thus  exposing  the  lateral  wall  of  the  pharynx  at 
the  situation  corresponding  to  the  tonsil.  The  pharynx  is  opened  and  the 
disease  is  removed  as  in  the  first  instance.  If  the  tissues  connected  with 
the  ramus  of  the  jaw  are  involved,  this  portion  of  the  bone  should  be  re- 
moved along  with  the  diseased  structures  connected  with  it.  The  elevation 
of  the  periosteum  at  the  inner  surface  in  such  cases  as  these  is  obviously  as 
unnecessary  as  it  is  unwise. 

The  General  Remarks. —  Treves  advises  the  passing  of  a  soft  catgut  liga- 
ture beneath  the  common  carotid,  so  that  haemorrhage  can  be  arrested 
promptly  in  case  of  need,  by  traction  on  the  ligature,  not,  however,  by 
tying  it.  After  operation  the  ligature  is  removed  and  the  wound  closed. 
If  haemorrhage  be  not  feared,  preliminary  ligature  of  the  external  carotid 
is  advisable,  since  this  measure  not  only  controls  haemorrhage,  but  like- 
wise arrests  the  freedom  of  the  circulation  of  the  part  for  some  time  to 
come,  and,  moreover,  offers  no  impediment  to  cerebral  circulation.  In 
those  cases  in  which  the  external  carotid  is  tied  and  the  operation  com- 
pleted at  once,  infection  of  the  wound  from  the  pharynx  may  lead  to 
cellulitis  of  the  neck,  and  to  secondary  haemorrhage  from  the  external 
carotid  at  the  seat  of  the  ligature.  Therefore,  in  our  last  case  of  this  kind, 
the  wound  was  packed  with  iodoform  gauze  for  three  days  before  the 
disease  was  removed.  During  this  time  reparative  closure  of  the  inter- 
stices of  the  entire  wound  had  taken  place,  and  but  a  very  limited  suppura- 
tion followed.  A  longer  time  than  this  can  be  taken  in  many  instances.  It 
is  essential  for  final  cure  that  the  lymphatic  glands  be  removed  irrespective 
of  the  appearance  in  them  of  infection,  as  it  is  a  well-established  fact  tliat 


578  OPERATIVE  SURGERY. 

these  glands  may  be  infected  without  causing  an  appreciable  increase  in  size. 
The  glands  and  the  associated  connective  tissue  should  be  dissected  away 
together,  thus  securing  the  removal  of  infected  glandular  and  other  lymphatic 
structures.  Two  wires  should  be  introduced  through  the  fragments  of  the 
jaw  at  some  distance  apart,  especially  in  the  posterior  division  of  the  bone, 
to  prevent  rotation  of  the  posterior  fragment,  which  is  quite  sure  to  happen 
if  but  one  be  employed.  The  interdental  splint  (Fig.  743)  finds  in  these 
cases  a  most  satisfactory  use. 

The  After-treatment. — Free  drainage,  thorough  cleanliness,  and  ample 
nutrition  by  means  of  the  stomach  tube  are  essential.  The  opening  in  the 
wall  of  the  pharynx  should  be  closed  at  once  as  far  as  possible  with  chromi- 
cized  catgut.  The  external  wound  is  closed  ;  drainage  and  moderate  pres- 
sure are  applied  to  the  surface.  If  an  opening  remain  in  the  pharynx, 
it  should  be  plugged  lightly  from  within  with  antiseptic  gauze  to  prevent 
infection  of  the  wound.  The  patient  should  be  got  out  of  bed  and  in  the 
fresh  air  as  soon  as  practicable.  He  should  be  caused  to  lie  on  the  well  side 
during  healing,  to  prevent  contact  with  the  raw  surfaces  of  the  buccal  dis- 
charges. 

Tlte  Results. — Late  detection  of  the  disease,  with  consequent  involvement 
of  the  glands,  renders  the  final  outcome  very  unsatisfactory  indeed.  However, 
sufficiently  favorable  results  have  followed  bold  and  extended  action  on  the 
part  of  many  surgeons  to  warrant  the  attempt  of  extirpation,  provided  proper 
co-operation  can  be  secured.  Bosworth  reports  but  one  cure — two  and  a 
half  years — in  118  cases.  Butlin  reports  54  cases,  with  14  deaths  from  opera- 
tion; 21,  alive  or  dead,  with  recurrence;  3  died  from  cancer  elsewhere;  9 
were  free  for  more  than  three  and  8  from  one  to  three  years.  Butlin  does 
not  favor  preliminary  tracheotomy. 

OPERATIOXS    ox   THE    XOSE. 

Phigging  of  the  Posterior  Nares  (Fig.  746). — Plugging  of  the  posterior 
nares  is  practiced  for  the  arrest  of  obstinate  epistaxis.  The  tampon  or  plug 
can  be  made  of  sponge,  lint,  or  of  suitable  cloth,  and  should  be  of  a  proper 
size  to  closely  fit  the  posterior  naris  of  one  side,  which  in  the  adult  is  about 
three  quarters  of  an  inch  long  and  half  an  inch  wide.  The  plug  is  made  by 
tying  a  strong  ligature  around  the  middle  of  the  selected  aseptic  material 
suitably  arranged  for  the  purpose,  the  ligature  including  within  its  grasp  at 
opposite  sides  of  the  plug  the  loops  of  two  other  strong  ligatures,  which  are 
in  turn  tied  firmly  to  the  primary  one  ;  the  ends  of  the  latter  after  tying  are 
cut  short.  A  plug  of  simpler  construction  than  this  is  often  employed  (Fig. 
746).  The  cannula  of  Bellocq  (Figs.  746  and  747,  f),  with  the  spring  with- 
drawn, is  then  carried  along  the  floor  of  the  nostril  to  the  posterior  wall  of 
the  pharynx,  when  the  movable  rod  is  projected  forward  into  the  mouth.  The 
extremities  of  the  loop  at  one  side  of  the  tampon  are  passed  through  the  eye 
of  the  instrument  with  which  they  are  drawn  through  the  meatus  by  first 
returning  the  central  rod  and  then  withdrawing  the  instrument  itself.  The 
tampon  is  now  carried  into  position  by  pulling  on  the  strings  which  have 
their  exit  through   the  nose,  aided  by  the  finger  carried  behind  the  soft 


()1'ki:a'I'I()Ns  (»n  tiik  nosk. 


57*J 


palate.  Siillicuc'iit  traction  is  matlo  to  forcibly  close  tlio  posterior  naris ;  tlio 
strings  in  front  are  then  tic^l  around  another  plug  similar  to  that  alreaijv 
used,  by  which  nu'ans  the  anterior  0|)enin<i:  is  closed  as  w(;ll.  The  |)hig 
should  be  well  carboli/ed  before  introduction,  and,  if  need  be,  can  be  wet 
with  an  astringent  solution.  Tlic  plug  is  rernovc(|  at  the  end  of  forty- 
eight  hours  by  pulling 
downward  on  the  strings 
rciuaiiiing  in  the  mouth 
supplemented  with  back- 
ward ])ressure  by  an  in- 
strument introduced  along 
the  floor  of  the  nostril.  If 
the  cannula  of  Bellocq  be 
not  available,  a  long,  flexi- 
ble probe,  an  ordinary  gum 
catheter  (Fig.  747,  c),  or 
even  a  common  wire,  may 
be  utilized  in  its  stead 
(Fig.  747,  c).  Sometimes 
the  string  is  carried  pref- 
erably through  the  nostril 
and  out  of  the  mouth  by 
means  of  the  cannula,  etc., 
or  other  instrument,  and 
then  attaclied  to  the  plug, 
instead  of  being  tied  to  it 
before  the  cannula  is  in- 
troduced. 

T//e  BeiiKirks.—U  the  plug  be  introduced  too  tightly,  sloughing  of  the 
mucous  membrane  may  ensue,  followed  even  by  necrosis  of  the  bones ;  also, 
the  removal  may  cause  quite  severe  bleeding.  If  haemorrhage  recur  after 
removal  of  the  plug,  the  nares  should  be  thoroughly  cleansed  before  an- 
other is  introduced,  to  obviate  the  danger  of  sepsis,  a  risk  that  is  propor- 
tionate to  the  length  of  time  that  the  plug  is  allowed  to  remain  in  place 
unchanged. 

The  Removal  of  Nasal  Polypi  (Forceps  or  Smire).— If  the  polypus  or 
the  pedicle  be  small,  the  growth  can  be  quite  readily  removed  by  the 
forceps  or  the  snare. 

If  the  forceps  be  employed,  the  patient  should  sit  in  a  chair  exposed  to  a 
bright  light,  witii  the  head  supported  by  an  assistant,  and,  after  spraying 
the  nares  with  a  strong  solution  of  cocaine,  the  point  of  attachment  of  the 
growth  is  seized  and  twisted  off  by  turning  the  instrument  repeatedly  on  its 
long  axis.  //'  i/ie  growth  be  attached  to  the  turbinated  bane,  it  may  be  neces- 
sary to  twist  and  pull  away  the  bone  structure  before  the  tumor  can  be 
removed.  In  such  a  case  as  this,  the  patient  should  be  placed  in  the 
recumbent  position  and  with  the  head  so  turned  as  to  cause  the  blood  to 
flow  from  the  nose  instead  of  into  the  pharynx.  An  anaesthetic  should  be  em- 
43 


Fi(i.  746. — Plugging  posteriur  nares. 


580 


OPERATIVE   SURGERY. 


ployed.  One  blade  of  the  forceps  is  passed  carefully  beneath  the  turbinated 
bone,  the  other  at  the  opposite  side,  and  when  closed  firmly  the  bone  is 
twisted  away  along  with  the  large,  and  often  with  unnierous  small  growths. 
If  the  growth  be  situated  far  back  or  hang  down  into  the  fauces,  it  may 
be  detached  by  the  finger  passed  behind  the  soft  palate.  If  this  plan  fail, 
the  tumor  may  be  snared.  In  snaring,  the  wire  loop  (Fig.  747,  c),  without 
or  with  the  cannula  (Fig.  T49).  is  passed  along  the  floor  of  the  nose  and  over 


EiG.  747. — Implements  eraploved  in  plugging  nares  and  in  removal  of  nasal 

growths,  etc. 
a.  Xasal  specula,     b.  Straight  and  curved  polypus  forceps,     c.  Gum  catheter,  Bellocq's 
cannula,  and  wire  loop  for   plugging,     d.  Polypus  snare,     e  and  /.  Extemporized 
tracheal  anaesthetizing  apparatus. 

the  tumor  by  aid  of  the  finger.  The  loop  is  tightened  and  the  growth 
severed.  The  growth  may  be  strangulated  by  means  of  intertwined  loops 
placed  around  the  pedicle  as  indicated  in  Fig.  ToO.  The  greater  length  of 
time  required  and  the  offensive  odors  that  often  attend  the  removal  do  not 
commend  the  method. 


Ol'KKA'llO.NS   ON    'I'lIK    N«tSK. 


581 


The   Removal    of   some   Nasal   and   Nasu  pharyngeal   Polypi.  —  in  ud- 

ri'iii(»\al     of     ii.isal     growths     (Ki^J. 


l'"i(;.   7-4S. —  Lnoj)  yiiideil  over  polyiiiis  willi  linger. 


(litioii  t(»  iiislnmu'iits  ciiijilini'tl 
747)  tht'if  may  he 
also  required  iiistrii- 
inents  for  ligature  of 
vessels  (Fig.  lOil);  for 
excision  of  the  jaw 
(Fig.  'Ml)  ;  ehisels 
and  mallet  (Fig.:5tM), 
and  for  traclieotomy 
and  traclu'al  ana's- 
thesiii  (pages  580  and 
l(i!S4).  An  abun- 
dance of  forcipres- 
sure,  ligatures,  anti- 
septic wipers  (Fig. 
GO),  and  gauze,  should 

be  provided.    .If  the  growth  be  fibrous  and  not  amenable  to  treatment  by  the 
previous  methods,  or  be  of  naso-pharyngeal  origin,  it  can  then  be  exposed 

either  by  way  of  the  nasal  palatine 
or  maxillary  routes.  The  nnsitl 
route  is  best  suited  to  the  re- 
moval of  growths  limited  to 
the  nasal  cavity.  They  may  be 
reached  by  turning  the  carti- 
laginous part  of  the  nose  aside 
(Desprez). 

The  Operatio7i. —  Locate  the 
free  margin  of  the  nasal  bone ; 
divide  the  skin  parallel  with 
this  margin  from  the  middle 
line  of  the  nose  down  to  the 
junction  of  the  cheek  and  nostril,  and  tlience  cut  downward,  ending 
in  the  nasal  orifice  of  the  oppo- 
site side ;  separate  the  cartilagi- 
nous from  the  bony  part  of  the 
nose  by  means  of  scissors,  and  the 
inferior  attachment  of  the  septum 
for  the  proper  distance  by  the  same 
means.  The  end  of  the  nose  is 
freed  and  turned  to  the  opposite 
side,  and,  if  additional  space  be 
required,  the  turbinated  bones  are 
removed.  After  removal  of  the 
growth,  the  end  of  the  nose  is  re- 
placed and  united  with  sutures  to  p,^  750.- Application  of  loops  for  tying 
the  divided  borders.  pedicle. 


FiCi.  74n. — Doulile  camnila  in  jiositioii. 


582 


OPERATIVE  SUR(JERY. 


Chassaignac's  Method. — Chassaiguac  carried  an  incision  from  near  the 
inner  cauthus  of  one  eye  directly  across  the  root  of  the  nose  to  a  point  cor- 
responding to  that  of  starting,  thence  downward  along  the  outer  side  of  the 
nose  through  the  alar  groove  across  close  beneath  the  end  of  the  nose  to  the 


^>v^- 


'ml 


Fig.    751. — Chassaignac's   method,   the  in- 
cision. 


Fig. 


r52. — Chassaignac's  method,   flap 
turned  aside. 


opposite  ala  (Fig.  751).  He  divided  the  bones  in  a  line  corresponding  with 
the  incision  of  the  soft  parts,  also  the  septum,  and  turned  the  nose  to  the 
opposite  side,  thus  exposing  freely  the  nasal  cavity  (Fig.  752). 

After  the  removal  of  the  growth,  the  parts  are  restored  to  their  normal 
position  and  the  edges  of  the  wound  united.  If  this  method  be  not  deemed 
advisable,  the  nose  can  be  turned  doivnward  by  making  a  U-shaped  incision 
down  to  the  bone,  the  convex  portion  of  which  shall  cross  the  root  of  the 
nose  between  the  eyes,  while  the  arms  extend  downward  at  each  side  of  the 
nose  to  the  outer  borders  of  the  alfe  (Oilier)  (Fig.  753,  a).    The  bones  are  then 

sawed  through  in  the  line  of  the  incision,  the  sep- 
tum liberated  at  their  under  surface,  and  the  nose 
turned  downward,  so  as  to  expose  the  interior  of 
the  nasal  cavity  to  observation  and  manipulation. 
If  the  growth  be  a  large  one  and  greater  space 
be  necessary,  the  incision  can  be  modified  (Fig. 
758,  a),  as  shown  by  the  dotted  line,  and  the 
bones  lying  in  its  course  sawed  through,  as  be- 
fore described,  care  being  taken  to  avoid  the 
roots  of  the  teeth.  After  the  removal  of  the 
growth,  the  parts  are  replaced  and  confined  in 
position  by  sutures,  dressings,  etc.  Naso-pharyn- 
geal  polypi  can  sometimes  be  removed  by  this 
method. 

In  1873  Rouge  described  the  following  method 
applicable  to  the  removal  of  diseased  bone,  obstinate  polypi,  and  even  small 
naso-pharyngeal  growths  when  located  well  in  front : 


Fig.  753. — a.  Ollier's  method. 
b.  Lawrence's  method. 


OI'I'IKATIONS   ON    'I'lIK    NOSE. 


583 


Rntff/r's  Mrtlind. — Uilli  tlu;  paticiit's  liciid  tiiiiicd  to  one  side  and  the 
upper  lip  driiwn  forcibly  upwiird  by  an  assistant,  the  surgeon  carries  a  curved 
scissors  close  to  the  bone  through  the  space 
lying  between  the  bicuspid  teeth  of  the  vc- 
spective  sides,  severing  the  soft  parts  uji 
to  anil  op|i(isitc  the  nasal  bones.  At  the 
same  time  the  (cartilaginous  septum  is  de- 
tached from  the  nasal  spine,  thus  permit- 
ting the  end  of  the  nose  to  be  turned  upward 
toward  the  forehead,  thereby  exposing  the 
anterior  nares  to  free  examination  (Fig. 
754).  After  removal  of  the  growth,  the 
parts  are  restored  to  their  nornuil  place  and 
held  there  by  careful  bandaging. 

Langenheck's  Method  (Fig-  755,  a). — 
Make  an  incision  from  near  to  the  center 
of  the  root  of  the  nose  obliquely  downward 
and  outward  on  the  outer  side  of  the  nose 
and  cheek  to  a  point  external  to  the  ala 
nasi.  Separate  the  upper  border  of  the  flap 
a  short  distance,  leaving  the  periosteum  ;  sever  the  alar  cartilage  from 
the  nasal  bone,  and  with  bone  nippers  sever  the  nasal  bone  from  its  fellow. 
Also  in  the  same  manner  divide  the  nasal  process  of  the  superior  maxilla 
at  its  base  through  to  the  margin  of  the  orbit  (Fig.  756).  The  entire  upper 
part  of  the  nasal  cavity  can  then  be  exposed  by  raising  upward  the  quadri- 
lateral piece  of  bone  thus  formed  of  both  the  nasal  bone  and  process  together. 


Fig.  754. — Rouge's  method. 


Fui.  755. — a.  Langen beck's  incthod. 
b.  Boeckel's  method. 


Fig.     756. — Langenbeck's    method,     flap 
turned  aside. 


After  the  tumor  is  removed  the  bone  flap  can  be  returned  and  fastened  in 
its  proper  position. 

Lawrence  s  Method  (Fig.  753,  b). — From  a  point  just  internal  to  the  lach- 
rymal sac,  make  an  incision  along  each  side  of  the  nose  to  the  junction  of  the 
ala  with  the  lip.  Sever  the  nasal  bones  and  the  nasal  processes  of  the  supe- 
rior maxilliB  with  bone  forceps,  thus  opening  into  the  nasal  cavity.  Divide 
the  septum  and  turn  the  nose  upward. 

The  Comments. — Rouge's  method  leaves  no  scar  and  the  parts  are  readily 
adjusted  without   sutures.      The   nose,  however,  should    be   supported   in 


584 


OPERATIVE  SURGERY. 


proper  shape  until  union  takes  place.  The  amount  of  room  provided  by 
these  operations  is  limited,  therefore  a  careful  determination  of  the  con- 
nections of  the  growth  must  be  made  before  operation,  to  avoid  unwise  or 
needless  mutilation. 

The  palatine  route  is  suited  for  the  treatment  of  more  difficult  cases  than 
is  the  nasal  one.  Naso-pharyngeal  as  well  as  nasal  growths  are  approachable 
through  this  channel  of  procedure. 

Nelaton's  Method  (Fig.  757,  a). — Make  an  incision  in  the  median  line 
through  the  uvula  and  soft  palate  down  to  the  bone  (a) ;  continue  it  forward 
along  the  posterior  half  of  the  hard  palate ;  two  other  incisions,  one  on 
either  side,  are  now  carried  obliquely  outward  from  the  anterior  extremity 

of  the  first  to  the  respec- 
tive alveolar  processes ;  these 
flaps,  including  the  perios- 
teum, are  reflected  outward 
with  a  rugine ;  the  hard  pal- 
ate is  perforated  and  cut 
away ;  the  periosteum  and 
mucous  membrane  of  the 
floor  of  the  nose  are  turned 
aside,  the  septum  is  removed 
if  necessary,  the  tumor  ex- 
posed to  view  and  excised. 
The  periosteal  flap  of  the 
hard  palate  should  be  re- 
turned to  the  normal  position 
and  stitched  in  the  usual 
manner.  The  cut  through 
the  soft  palate  can  be  joined 
then  or  subsequently,  accord- 
ingly as  the  operator  desires. 
If  the  growth  be  a  small  one, 
but  one  side  of  the  hard  pal- 
ate need  be  attacked. 

Chalofs  Method.— jyivicie 
the  gingivo-labial  fold  and  separate  the  upper  lip  from  the  bone  at  a  point 
corresponding  to  the  anterior  nasal  spine,  thus  opening  into  the  nasal 
fossae  in  front.  Draw  the  canine  teeth,  open  the  mouth  widely,  and  make 
an  incision  down  upon  the  under  surface  of  the  hard  palate  at  either  side 
close  to  the  alveolus,  beginning  at  the  empty  socket  of  the  canine  tooth, 
and  terminating  at  the  posterior  border  of  the  bone  (Fig.  757,  b,  b) ;  divide 
the  alveolus  and  hard  palate  at  either  side  in  the  line  of  incision  with 
chisel  and  mallet;  separate  the  bony  flap  thus  formed  from  its  connec- 
tions with  the  vomer  and  nasal  mucous  membrane ;  displace  it  downward 
and  backward  into  the  mouth,  the  velum  acting  as  a  hinge ;  remove  the 
growth ;  restore  and  fasten  the  bone  flap  in  place  with  wire  sutures.  This 
procedure  is  ingenious  and  effective  except  when  the  growths  are  large  and 


Pifi.  75^ 


iS'eialoii's  method,     b.  C/halot's  method. 


OPKRATIONS  ON    '11  IK    NOSK.  5^5 

locuti'd  at  till'  vault  of  tin-  jiliaiviix.  The  cle^n'tH!  of  lia'iiiorrlia^o  iti  this 
oi)eratii>ii  is  an  important  item,  and  sugfjosts  the  advisability  of  tracheotomy 
and  a  ))haryng('al  tam[)()n  as  wise  preliminary  measunjs,  especially  as  the 
presence  of  the  l)one  llap  will  impede  the  manipulations  of  the  surgeon. 

A)iii(tii(lah'\'<  McUkiiI. — Expose  the  anteiior  nares  as  advised  by  Rouge 
(page  AS!));  divide  tlui  bony  septum  at  its  connections  with  the  maxilhe; 
open  the  mouth  widely  and  make  an  incision  in  the  median  line  of  the  hard 
palate  down  to  tlu'  hone;  remove  a  middle  incisor  if  need  be,  and  divide  the 
alveolus  and  hard  i)alate  in  the  median  line  with  a  small  saw  introdiu-ed 
througli  the  nose.  The  soft  palate  is  not  disturbed  unless  the  size  or  position 
of  the  morbid  growth  calls  for  it.  The  maxilhi;  are  pried  aj)art  or  drawn 
asunder  with  hooks,  if  required,  carefully  avoiding  displacement  of  the 
nasal  bones  by  severing  their  connections  with  the  nasal  processes  of  the 
superior  maxilhv,  if  called  for,  the  tumor  is  exposed  and  removed  with 
forceps,  scissors,  scoops,  etc.  'J'horough  disinfection,  and  packing  with 
antiseptic  gauze  follows  the  removal,  succeeded  by  restoration  and  wiring  of 
the  bones  in  the  ])roj)er  position.  The  soft  palate  should  be  closed  at  tlie 
same  time  if  the  condition  of  the  patient  does  not  contra-indicate  it.  This 
operation  offers  the  most  room  of  any  by  this  route,  with  no  loss  of  structure 
or  resulting  deformity. 

The  maxiUary  route  is  selected  when  the  size  and  nature  of  the  growth 
render  the  preceding  ones  dangerous  on  account  of  the  hindrance  due  to  the 
limited  space  available  for  operation.  A  preliminary  tracheotomy  is  advisable 
if  the  tumor  be  large,  of  broad  origin,  or  nnusually  vascular. 

BoeckeVs  Method. — Make  an  incision  down  to  the  bone  from  near  the 
root  of  the  nose  along  its  side  to  the  groove  of  the  nostril  and  cheek,  thence 
in  a  curved  direction  outward  and  backward  on  the  cheek  to  a  point  verti- 
cally below  the  middle  of  the  orbit  (Fig.  755,  h).  A  second  incision,  begin- 
ning at  the  upper  end  of  the  first,  is  carried  outward  along  the  lower  margin 
of  the  orbit  down  to  the  bone  ;  raise  the  flap  with  the  periosteum  from  the  bone 
with  a  rngine  or  periosteotome,  exposing  the  lower  portion  of  the  nasal  bone 
and  the  entire  width  of  the  nasal  ])rocess  of  the  superior  maxilla,  carefully 
avoiding  the  lachrymal  sac  and  the  infra-orbital  nerve;  define  the  bone  flap 
(Fig.  338,  D)  with  chisel  and  mallet,  commencing  at  the  inner  border  of  the 
infra-orbital  canal  and  going  vertically  downward  to  opposite  the  floor  of 
the  uaris,  thence  inward  to  the  naris  itself;  then  divide  the  bone  in  front 
of  the  lachrymal  sac,  the  nasal  process  its  entire  width,  and  finally  cut  down- 
ward and  inward  through  the  lower  portion  of  the  nasal  bone  by  similar 
means,  the  chisel  going  into  the  nose  throughout  the  entire  course  of  the 
bony  incision.  Remove  the  bone  section,  thus  exposing  the  nasal  cavity, 
which  exposure  can  be  still  further  increased  by  removal  of  the  turbinated 
bones.  After  removal  of  the  growth  the  opening  is  closed  by  returning 
and  suturing  in  place  the  periosteal  flap. 

La)ige}ibeel-''s  Operation. — Make  a  slightly  curved  incision  with  the  con- 
vexity downward,  extending  from  the  ala  of  the  nose  to  the  malar  bone,  and 
thence  as  far  backward  as  the  middle  of  the  zygoma.  A  second  incision  is 
made,  beginning  near  the  center  of  the  root  of  the  nose,  and,  passing  along 


586 


OPERATIVE   SURGERY. 


the  inferior  margin  of  the  orbit,  to  join  the  former  near  the  middle  of  the 
malar  bone  (Fig.  758,  c).  These  incisions  should  extend  down  to  the  bone; 
the  soft  parts,  however,  are  not  to  be  raised,  with  the  exception  of  the  peri- 
osteum of  the  floor  of  the  orbit,  which  should  be  raised  if  the  orbital  plate  is 
to  be  removed.  Separate  the  masseter  muscle  from  the  malar  bone ;  divide 
the  buccal  fascia ;  depress  the  inferior  maxilla,  and  pass  a  pointed  elevator,  or 
the  finger  if  possible,  into  the  posterior  nares,  carrying  it  by  way  of  the 
lateral  opening  through  the  pterygo-maxillary  fissure  into  the  spheno-maxil- 
lary  fossa,  thence  through  the  spheno-palatine  foramen,  all  of  which  passages 
may  have  been  distended  by  the  morbid  growth.  A  small  keyhole  saw  is 
passed  by  the  same  route,  and  the  superior  maxilla  divided  from  behind  for- 
ward in  the  line  of  the  lower  skin  incision  (Fig.  338,  F,  F).  The  extremity  of 
the  saw  is  covered  by  the  end  of  the  index  finger  carried  into  the  pharynx 
through  the  mouth,  to  protect  the  tissues  from  being  injured  by  it.  The 
zygomatic  process  of  the  temporal,  frontal  process  of  the  malar,  and  orbital 
plate  of  the  superior  maxilla  are  then  sawed  through  from  behind  forward  to 
the  lachrymal  bone,  the  saw  here  being  made  to  pass  in  its  course  through 
the  spheno-maxillary  fissure.     Or  the  superior  maxilla  can  be  divided  in  the 

line  of  the  superior  incision  of  the  soft  parts, 
thus  leaving  the  orbital  plate  intact.  The 
osteo-cutaneous  flap  is  now  raised  by  an  ele- 
vator carried  beneath  the  malar  bone  and 
slowly  lifted  upward  and  inward  toward  the 
nose,  the  bones  and  soft  parts  of  which  form 
a  hinge  to  the  flap  at  that  side.  If  the  saw 
can  not  be  passed  into  the  posterior  nasal 
cavity  even  by  the  aid  of  a  grooved  director, 
the  lips  of  the  incision  of  the  soft  parts 
may  be  drawn  asunder,  and  the  bone  sawed 
from  without  inward  and  before  backward. 

The  Comments. — The  operation  is  usually 
attended  by  quite  severe  haemorrhage,  which, 
however,  can  be  controlled  readily  by  pressure 
and  an  occasional  ligature.  After  the  re- 
moval of  the  growth,  the  parts  are  adjusted 
and  confined  in  position  by  sutures,  etc.  If 
the  growth  to  be  removed  be  a  large  and  vas- 
cular one,  a  preliminary  tracheotomy  should 
be  done.  If  it  be  malignant  or  very  vascular,  and  have  a  large  attachment,  we 
deem  it  a  wise  precaution  to  tie  both  external  carotids  prior  to  removal.  The 
dangers  from  haemorrhage  will  be  lessened  by  this  measure,  and,  moreover, 
the  diminished  vascularity  of  the  parts  will  hinder  the  redevelopment  of  the 
growth.  Daivbarn  practices  the  removal  of  these  vessels  and  for  similar 
reasons. 

The  division  of  the  bones  can  be  readily  and  advantageously  done  with 
an  osteotome  and  mallet  (Fig.  394),  especially  when  the  spaces  at  the  back 
of  the  jaw  are  not  sufficiently  distended  by  the  growth  to  permit  a  wise  use 


Fig.  758.— «.  Ollier's 
Guerin's  incisions 
beck's  incision. 


incision,    b. 
c.  Langen- 


Ol'llKATKtNS   UN    TIIK    NoSK. 


587 


of  the  sjiw.  'l"lu'  (lilliciilty  of  niisiiij,'  tlu;  llap  uud  of  R-Liirniii^f  and  j)roporly 
ailjustiiij^  it,  tlu'ii'hy  inciniiii^  the  ilaii<,'ers  of  necrosis,  with  consequent  sepsis 
and  non-nnion,  are  ohjei'tionahlc  features  of  the  measure. 

'J'lie  JicsiiKs. — 'rh(!  rate  of  mortality  from  tliis  method  is  less  than 
twenty-five  jier  cent,  and  (k'peiids  more  on  thi;  dangers  arising  from  the 
removal  of  tiie  growth  than  those  tlie  result  of  the  steps  necessary  to  reach 
it.  'I'he  mortality  is  greater  wiicn  the  oj)eration  is  done  through  tlu;  hard 
palate  than  when  performed  by  means  of  the  displacement  of  the  upjicr  jaw. 

Gneriii's  Method. — Make  an  incision  along  the  facial  line  from  the  ala 
of  the  nose  to  the  angle  of  the  mouth  ;  dissect  up  the  soft  parts,  opening 
the  nostril,  and  bare  the  malar  process  of  the  superior  maxilla;  introduce 
a  saw  or  chisel  into  the  nose  and  divide  entirely  the  maxilla  horizontally 
backwanl  below  the  infraorbital  canal ;  separate,  through  the  mouth,  the  soft 
from  the  hard  palate  with  a  scalpel;  remove  a  middle  incisor  tooth  and 
divide  the  hard  palate  in  the  median  line  with  a  saw  or  chisel.  The  frag- 
ment is  then  taken  away  with  lion-jaw  forceps. 

TJie  liemarks. — This  operation  is  an  excellent  one  so  far  as  deformity  is 
concerned,  and  can  be  practiced  even  without  division  of  the  lip.  The 
employment  of  an  artificial  appliance  to  the  roof 
of  the  mouth  will  remedy  the  resulting  defect  in 
speech  (page  320). 

Kochcr's  Method. — Place  the  patient  in  Rose's 
position  and  divide  the  upper  lip  from  above 
downward ;  sever  transversely  down  to  the  bone 
the  reflection  of  the  mucous  membrane  above  the 
alveolar  process ;  with  a  chisel  cut  through  ob- 
liquely on  a  level  with  the  nasal  process  the  supe- 
rior maxillary  bones  (Fig.  759) ;  divide  the  alveo- 
lar process  aiul  the  hard  palate  in  the  median 
line  and  draw  the  bones  apart  with  hooks ;  in- 
cise the  mucous  membrane  of  the  floor  of  the 
nasal  fossa  close    to  the  septum,  and   push  the 

vomer  to  the  opposite  side,  thus  exposing  freely  to  observation  the  naso- 
jiharyngeal  space.  After  removal  of  the  tumor,  restore  and  fasten  the  parts 
in  position  with  wire  or  an  interdental  splint. 

Cheever's  Method.— In  Chcever's  case  both  superior  maxilla?  were  re- 
moved, owing  to  the  large  size  and  central  situation  of  the  growth.  Cheever 
made  an  incision  from  near  the  inner  canthus  on  each  side  of  the  nose, 
downward  along  the  natural  furrow,  arouiul  the  ahv  to  the  median  line  of  the 
lip,  which  he  divided.  These  flaps  were  reflected  upward  and  outward  hs  far 
as  the  malar  prominences,  and  the  body  of  each  superior  maxilla  was  sawed 
from  behind  forward  to  the  middle  meatus  of  the  nose ;  the  septum  and  vomer 
w^ere  cut  with  scissors;  the  jaws  were  then  depressed  and  the  tumor  removed, 
after  which  the  bones  were  replaced  and  wired  in  position.  The  loss  of 
blood  was  not  great,  but  the  patient  died  on  the  fifth  day  from  exhaustion. 

The  General  Comments. — The  excision  of  the  entire  upper  jaw  may  be 
practiced  for  the  removal  of  neoplasms,  or  only  the  portion  below  the  line 


Fi(i.  759. — Kocher's  iiu'tliod. 


58S  OPERATIVE   SURGERY. 

of  the  orbital  floor  may  be  removed.  The  superior  maxilla  can  be  raised 
ajid  turned  outward  on  a  hinge  formed  b}'  the  zygomatic  process  of  the 
malar  bone  and  the  contiguous  soft  parts  by  dividing  the  bone  in  the  line  of 
Ferguson- Webber's  incision  (Fig.  333,  b,  b'),  the  upper  portion  of  which,  for 
this  purpose,  should  be  extended  to  the  malar  bone.  The  maxillae  are  sep- 
arated by  sawing  through  the  hard  palate  and  alveolar  process,  and  the  nasal 
bone  is  disconnected  from  the  superior  maxilla  by  severing  its  connections 
with  bone  forceps.  The  osteocutaneous  flap  can  then  be  raised  and  swung 
outward.  If  necessary,  the  soft  palate  may  be  divided.  After  the  removal 
of  the  growth,  the  parts,  including  the  soft  palate,  are  adjusted  and  joined 
by  sutures. 

With  the  view  of  avoiding  as  far  as  possible  the  division  of  the  terminal 
filaments  of  the  superior  dental  nerve,  and  obviating  the  loss  of  function 
incident  thereto,  Langenbeck  recommended  that  a  curved  incision  be  made, 
crossing  the  cheek  about  midway  between  the  angle  of  the  mouth  and  the 
lower  border  of  the  orbit,  beginning  near  the  lower  end  of  the  nasal  bone 
and  extending  downward  and  outward  and  then  upward,  so  as  to  avoid 
Steno's  duct.  The  flaps  are  dissected  from  the  superior  maxilla,  which  is 
removed  through  the  opening  made  in  the  soft  parts.  If  the  whole  bone  is 
to  be  excised,  the  integrity  of  the  superior  maxillary  nerve  can  be  still  fur- 
ther preserved  by  removing  it  in  advance  from  the  infra-orbital  groove  by 
the  aid  of  a  fine,  sharp  chisel. 

The  removal  of  a  growth  of  any  great  size  from  the  posterior  nares  or 
pharynx,  especially  the  latter,  will  be  attended,  if  its  attachment  be  exten- 
sive, by  the  entrance  of  a  large  amount  of  blood  into  the  pharynx  and 
trachea ;  it  is  therefore  wise  to  do  a  preliminary  tracheotomy,  so  that  the 
lower  extremity  of  the  pharynx  may  be  closed  by  sponges  or  otherwise 
tamponed.  If  the  shoulders  be  elevated  and  the  head  allowed  to  fall  far 
backward,  the  blood  can  be  removed  from  the  dependent  portion  of  the 
pharynx  as  fast  as  it  collects ;  this  position,  however,  impedes  respiration  by 
overextending  the  muscles  that  act  on  the  os  hyoides.  If  a  preliminary 
tracheotomy  be  done,  the  anesthetic  must  be  administered  through  the 
tube.  The  apparatus  devised  for  this  purpose  by  Trendelenburg  (Fig.  1283) 
mav  be  used  entire,  or  only  the  inhaling  portion  attached  to  the  ordinary 
tracheotomy  tube  can  be  employed ;  the  latter  plan  is  generally  to  be  pre- 
ferred, since  the  rubber  tampon  attached  to  this  tube  often  causes  bronchial 
irritation  when  inflated;  moreover,  if  it  become  ruptured  during  the 
course  of  an  operation,  or  be  imperfectly  distended,  blood  may  enter  the 
trachea  unawares. 

Krfemporized  substitutes  for  this  purpose  can  be  provided  if  a  rubber 
tube  of  suitable  size  and  length  be  attached  by  one  extremity  to  the  trache- 
otomv  tube,  and  the  other  be  inserted  loosely  into  the  bottom  of  an  empty 
quarter-pound  ether  can  and  fastened  there,  and  a  sponge  be  introduced 
into  the  can  and  kept  moistened  with  ether  (Fig.  747,  /).  The  ana?sthesia 
thus  produced  will  be  eminently  satisfactory  and  the  outlay  nominal.  In 
the  absence  of  the  ether  can,  pass  the  end  of  the  rubber  tube  through  a 
tightly  fitting  opening  in  the  center  of  a  pasteboard  diaphragm  properly 


()|'i;i:ati()Ns  on  tiiI';  nosk.  5^<j 

juljusU'd  to  a  <j^l:iss  tiunblcr  in  the  l)ott()in  of   wliicli   rests  a  sponge  mois- 
tened with  ether  (Fig.  747,  <■). 

The  choice  of  oporation  is  regulated  largely  indeed  by  the  size,  situation, 
attaeluncnts,  vascularity,  and  nature  of  the  growth.  If  the  growth  be  com- 
paratively small,  with  a  well-delined  pedicle,  and  acctcssible  through  the  nose, 
this  channel  may  be  adopted.  Annandale's,  Hoeckel's,  and  (luerin's  methods 
are  suited  to  the  treatment  of  large  naso-pharyngeal  growths.  Langen- 
beck's  method  is  quite  commonly  practiced,  and  is  an  admirable  one,  espe- 
cially when  the  naso-i)haryn\  is  much  distended  by  the  growth.  The 
removal  entirely  or  the  swinging  outward  or  inward  of  the  superior  maxilla, 
after  free  incision,  affords  a  tine  exposure  of  the  naso-pharynx,  especially 
the  removal  of  the  bone.  In  one  instance  the  author  practiced  removal 
with  great  operative  satisfaction,  and  followed  with  but  slight  cosmetic 
defect. 

The  afier-treatment  is  essentially  that  for  removal  of  the  jaw  (page  325). 

The  Results. — About  twenty-five  or  thirty  per  cent  die  from  the  oper- 
ation. Here,  as  in  excision  of  the  jaw  for  other  reasons,  septicaemia,  etc., 
claim  a  share  of  the  victims.  According  to  Lincoln,  twenty  per  cent  die 
from  the  operation,  and  in  about  thirty-six  per  cent  the  disease  returns 
within  twelve  months  after  the  operation.  We  are  disposed  to  regard  the 
latter  figures  as  having  a  decidedly  optimistic  expression. 

Deviation  of  the  Septum  Nasi. — It  not  infrequently  occurs  that  both 
the  bony  and  cartilaginous  portions  of  the  septum  are  deflected  to  such  an 
extent  as  to  seriously  interfere  with  breathing  through  the  nose  during 
attacks  of  coryza,  and  likewise  to  impart  a  distinct  nasal  twang  to  the  voice. 
This  deformity  may  or  may  not  be  associated  with  external  modifications  of 
the  nasal  symmetry.  In  either  case  the  indications  remain  the  same — to 
overcome  the  deformity  and  to  maintain  the  corrected  relations  of  the  {)arts 
until  recovery  takes  place. 

Tlie  Operation. — The  deformity  can  be  overcome  by  grasping  the  abnor- 
mal septum  between  the  blades  of  a  forceps  especially  designed  for  the  purpose 
(Fig.  7G1,  /),  which  are  thrust  into  the  anterior  nares  and 
closed  upon  the  deformed  septum  and  held  for  a  few  moments 
with  suflficient  firmness  to  press  its  irregularities  into  a  nor- 
mal position.  This  resistance  is  still  further  overcome  by  cau- 
tiously turning  the  forceps  from  side  to  side  on  its  long  axis. 
The  pressure  exerts  a  crushing  and  compressing  influence  on 
the  septum,  permitting  of  its  being  pressed  into  a  normal  po- 
sition. The  retentive  apparatus  is  a  specially  constructed 
clamp  (Fig.  760),  which  is  screwed  into  position  while  grasp- 
ing the  septum.  This  instrument  retains  the  part  thus  rec- 
tified until  the  reparative  ])rocesses  necessary  to  permanency 
shall  have  taken  place.  The  clamp  may  remain  in  position 
two  or  three  days,  not  tightly  screwed,  for  this  would  cause  ^,|jj„^g-g  damns 
ulceration,  but  closely  enough  to  exert  a  gradual  controlling 
influence  on  the  structure.  This  indication  can  likewise  be  well  met  by 
introducing  into  each  nostril   rubber  tubes  of  proper  size  and  length,  sur- 


590 


OPERATIVE   SURGERY. 


i-ouiided  by  oiled  lint.  After  three  or  four  days  either  of  the  preceding 
appliances  should  be  replaced  by  splints  (Fig.  761,  e,  A,  d)),  which  are  pushed 
into  each  nostril  and  worn  at  night  only.  This  treatment  is  annoying  and 
even  attended  by  positive  discomfort,  but  the  good  result  will  amply  repay 
the  patient  for  the  infliction  incurred.  Other  operations  are  recommended, 
such  as  the  removal  of  the  inferior  turbinated  bone  on  the  side  of  the  deflec- 
tion;  or  punching  the  septum  to  establish  a  communication  between  the 
closed  and  the  unclosed  nostrils.  Neither  of  these  acts  rectify  the  deformity, 
and  both  are  open  to  objections,  the  former  of  a  physiological,  the  latter 
of  a  mechanical  nature.  The  removal  of  the  projecting  portion  of  the 
cartilage  and  its  mucous  membrane  is  likewise  commended.  The  taking  away 
of    the   deformed  septum,  together  with  a  portion  of  the  superior  maxilla 


Fi(i.  701. — Iijstruiiieiits  employed  iTi  treatment  of  deviation  of  the  nasal  septum. 
a.  Douglass's  knives,     b.  Mial's  and  Curtis's  saws.     c.  Bosworth's  saw.     e,  h,  d.  Asch's, 
McKernon's,  and  Douglass's  nasal  s{)lints.    f.  Asch's  scissors  and  septum  compressor. 
i.  Douglass's  perforator,     g.  Elevator. 

(Post),  accomplished  by  separating  the  side  of  the  nose  from  the  cheek, 
and  turning  the  nose  over,  thus  gaining  access  to  the  obstruction,  con- 
stitutes an  operation  whose  seventy  is  out  of  proportion  to  that  of  the 
primary  difficulty,  and  may  be  followed  by  an  unsightly  scar.  It  is  recom- 
mended also  that  the  meatus  be  burred  out  (Wagner)  by  means  of  the 
dental  engine.  The  reported  results  certainly  give  strong  testimony  in 
favor  of  this  proposition.  The  deformed  portion  of  the  septum  may  be 
sawed  off  on  a  plane  conforming  to  that  of  the  remaining  portion  by  first 
applying  a  strong  solution  of  cocaine  to  it,  then  removing  the  deformity 


ol'KKATloNS   ON    'IIIK   ( liSOl'Fl A(]L'S.  5<J1 

with  ;i  narrow,  fine  saw  (I'i;;.  T<il,  r)  constructed  especially  for  the  purpose. 
This  plan  is  practiced  by  Bosworth,  and  it  appears  to  be  preferable  to  burring 

or  puiu'liinj^'  the  septum. 

Till-:    OI'KKATION'S    ON'    THK    (KSOIMIAO  L'S. 

The  nature  of  the  functions  and  the  important  intimate  anatomical 
environments  of  the  tesopliagus  contribute  greatly,  indeed,  to  the  difliculty 
of  treatment  of  this  passage,  and  also  favor  the  development  in  it  of 
obstructive  changes  of  grave  import.  The  anatomical  relations  of  this  tube 
should  be  carefully  considered,  and  the  possibilities  of  a  cure  cautiously 
weighed,  before  active  interference  is  begun.  Otherwise,  what  appears  to 
be  a  simple  matter  and  qnickly  curable  may  by  illogical  effort  become  sud- 
denly of  the  greatest  import  and  of  irremediable  nature. 

T//e  Afuiiuniiail  Points. — Tlie  oesophagus  begins  at  the  cricoid  cartilage 
on  a  level  with  the  sixth  cervical  vertebra.  It  lies  in  the  median  line  at  the 
beginning,  but  bears  off  half  an  inch  toward  the  left  in  the  cervical  region ; 
then  returns  to  the  median  line  at  the  fifth  dorsal  vertebra  and  again  tends 
slightly  toward  the  left  as  it  passes  through  the  diaphragm,  terminating 
opposite  the  ninth  dorsal  spine  behind,  which  corresponds  to  the  left  seventh 
chondro-sternal  junction  in  front.  In  a  sagittal  direction  the  oesophagus 
corresponds  to  the  curves  of  the  portions  of  the  spinal  column  with  which 
it  is  associated.  The  average  diameter  is  about  four  fifths  of  an  inch  ;  the 
smallest — a  little  more  than  half  an  inch — is  wisely  placed  at  the  beginning 
of  the  tube ;  the  second  narrowing  is  opposite  the  fourth  dorsal  vertebrje, 
the  third  at  the  diaphragm.  The  narrowest  parts  can  be  dilated  to  three 
fourths  of  an  inch  and  the  remainder  to  an  inch  and  a  half  in  the  dead 
subject.  The  transverse  diameter  exceeds  the  antero-posterior.  Since  these 
measurements  are  based  on  post-mortem  experiments,  they  can  be  regarded 
only  as  indicating  rather  than  establishing  the  limits  of  dilatation,  a  fact 
which  is  emphasized  frequently  in  the  living  by  the  ready  passage  along  the 
oesophagus  into  the  stomach  of  articles  of  much  greater  dimensions  than  are 
those  assigned  to  the  passage  itself.  When  empty  the  oesophagus  appears  as 
a  flat  muscular  tube.  Ogsfan  considers  that  food  traverses  the  normal 
oesophagus  in  about  four  seconds.  Cannon  and  Moser  determined  that 
fluids  "  are  propelled  deep  into  the  oesophagus  "  at  the  rate  of  seven  feet  per 
second. 

The  consultation  of  a  text-book  on  anatomy  will  promptly  suggest  those 
important  relations  which,  in  the  presence  of  disease  or  invasion,  invite  dis- 
aster if  unwisely  disturbed.  The  trachea,  carotid  vessels,  aorta,  pericardium, 
left  bronchus  and  medi:i>tinnm.  are  of  special  importance  in  this  regard. 

Foreign  Bodies  in  the  (Esophagus.— The  nature,  shape,  and  size  of  the 
foreign  body,  together  with  the  situation  and  time  of  impaction  and  the 
symptoms,  must  be  ascertained  with  deliberation  if  the  condition  of  the 
patient  will  permit.  Foreign  bodies  are  arrested  commonly  at  the  narrowest 
parts  of  the  oesophagus,  therefore,  usually  at  the  beginning.  At  this  situa- 
tion the  foreign  body  can  be  easily  touched  with  a  probang  and  often  with 
the  index  finger,  although  not  without  causing  the  patient  distress  if  con- 


592 


OPERATIVE   SURGERY 


sciousness  be  present.  Careful  examination  of  the  left  side  of  the  neck, 
behind  the  cricoid  cartilage,  will  often  disclose  the  presence  of  the  obstruction. 
When  situated  lower  down,  the  probang  and  bougie  will  establish  the  fact  (Fig. 
7G2).    After  failure  of  the  simpler  means  of  removal — i.  e.,  external  manipu- 


PiG.  762. — Instruments  employed  in  renioviil  of  foreign  bodies  from  cfisophagus. 
a.  Bristle  probang.  opened  and  closed,     b.  Coin  catcher  and  sponge  probang,  whalebone, 
r.  Roe's   flexible   coin   catcher,      d.  Tiemann's   flexible   cork-cateliing   forceps,      e. 
Cusco's  throat  forceps.    /  and  g.  Curved  throat  forceps.     Curved  forceps  of  different 
patterns  may  be  employed. 


lation,  emesis,  etc. — the  obstruction  is  usually  removed  at  the  higher  situation 
with  throat  forceps  designed  for  the  purpose  (Fig.  762,  e),  or  by  the  bucket 
probang  (J),  or  by  a  loop  of  wire,  or  other  simple  devices  of  this  character. 
However,  if  the  obstruction  have  been  lodged  here  for  some  time,  conse- 


OlMlliA  ri(»\S   ON    TIIK   (i;S(HMI.\(lt'S. 


593 


(|ii('nt  swclliii<,r  (»f  ilu'  soft  [i.-uts,  or  irrt'<;iil:iriiic.s  of  llu-  fort'i<,ni  body,  may 
n-iulcT  rcriioval  by  wiiy  of  tlu-  mouth  iinpossiblo.  Tlie  siirue  may  be  said 
also  of  for('i«,ni  bodies  lociitcd  elsfwliuro  in  the  tube.  The  bristle  and  the 
sponge  i)rol)iing  (Fii(.  7i'>2,  a,  0)  are  the  common  implements  for  removal 
under  these  circumstances. 

The  ficinarks. — It  is  seldom  indeed  that  a  foreign  body  causes  complete 
occlusion  of  the  u'sophagus.  Those  too  large  to  enter  it  encroach  not  infre- 
quently on  the  larynx  and  cause  death  from  suffocation.  The  lodgment  of 
an  article  near  the  cardia  is  specially  dangerous  because  of  the  i)roximity  of 
the  heart,  great  vessels,  and  i)leura.  While  all  bodies,  irrespective  of  their 
physical  characteristics,  lodge  most  frequently  at  the  established  narrowings 
of  the  Q'sophagus,  irregular  and  sharj)  ones  may  lodge  between  these  j)oints, 
but  round  and  Hat  ones  do  not.  External  manipulation  for  removal  is 
ap])licable  only  to  the  obstructions  located  in  the  cervical  portion,  and  should 
not  be  practiced  in  the  event  of  firm  impaction  or  when  marked  asperities 
characterize  the  obstructing  agent. 

The  Introduction  into  the  (Esophagus  of  Instruments.— The  introduction 
of  an  instrument  into  the  o'so])lKigus  is  usually  a  simple  procedure. 

A  Method  of  Introduction  of  a  Stomach  Tube. — Place  the  joatient  in  a 
good  light  while  in  a  chair  or  sitting  up  in  bed  ;  tip  the  head  backward  and 
give  it  in  charge  of  an 
assistant ;  gag  the  mouth  ; 
seize  the  tongue  (guarded 
from  slipping  with  a  dry 
cloth)  with  the  thumb 
and  fingers  and  draw  it 
forward,  thus  advancing 
the  larynx  ;  grasp  the  pre- 
viously warmed  and  oil- 
smeared  instrument  light- 
ly in  the  right  hand  ;  carry 
the  end  downward  and 
backward  to  the  poste- 
rior wall  of  the  pharynx; 
push  it  along  as  the  pa- 
tient gags,  and  cause  him  to  swallow  as  the  advancing  extremity  engages  in 
the  lower  part  of  the  pharynx;  advance  the  instrument  with  gentleness, 
heeding  the  presence  of  spasm  or  other  obstruction,  until  finally  the  instru- 
ment ]'>;isses  readily  along  the  oesophagus  into  the  stomach. 

Other  Methods  of  Introduction. — Instead  of  grasping  the  tongue  tlie 
index  finger  can  be  introduced  as  a  guide  to  the  advancing  instrument,  as  is 
commonly  practiced  in  the  introduction  of  an  oesophageal  bougie,  conducting 
it  safely  over  the  larynx  to  the  posterior  aspect  of  the  pharynx  (Fig.  T<»3). 
Solis-Cohen  recommends  the  drawing  of  the  larynx  forward  with  the  thumb 
and  fingers  applied  without.  The  accomplishment  by  this  method  requires 
the  employment  of  a  firm  and  somewhat  painful  pressure  (except  perhaps  in 
the  presence  of  anaesthesia)  that  is  out  of  proportion  to  the  demands  of  the 


Fic.  ICv^. — Introducing  tube  into  a?soi)hagus. 


594  OPERATIVE  SURGERY. 

case.  The  location  of  the  obstruction  can  be  estimated  by  recalling  the  fact 
that  in  the  average-sized  adult  the  distance  from  the  diaphragmatic  narrow- 
ing of  the  oesophagus  to  the  upper  incisor  teeth  is  about  fourteen  inches 
and  a  half,  and  from  the  aorta  and  from  the  upper  end  of  the  oesophagus  to 
the  same  teeth  is  nine  and  five  and  a  half  inches  respectively.  These  facts 
are  of  immense  importance  as  bearing  on  the  relation  of  the  obstructing 
agent  to  important  organs  and  the  liability  of  serious  complications  from 
the  passage  and  from  the  effects  of  the  means  employed  for  relief. 

The  Precautions. — The  introduction  into  and  passage  along  the  oesopha- 
gus of  a  probang,  bougie,  etc.,  and  the  manipulation  of  the  foreign  body 
should  be  conducted  with  great  care  and  a  minimum  expenditure  of  force, 
otherwise  perforation  will  ensue,  and  especially  is  this  true  in  those  cases 
characterized  by  the  structural  changes  incident  to  disease  and  ulceration  of 
the  walls  of  the  tube.  Avoid  entering  the  larynx  with  the  instrument. 
Coughing  and.  continued  spasm  of  the  larynx  with  the  advance  of  the  instru- 
ment indicate  laryngeal  invasion.  The  escape  of  air  through  a  hollow 
instrument  under  these  circumstances  is  diagnostic  of  entry  to  the  larynx. 
Observe  that  the  end  of  the  advancing  instrument  be  not  curved  forward, 
but  instead  that  it  lies  in  contact  with  the  posterior  wall  of  the  pharynx.  A 
cautious  advance  in  the  presence  of  spasm  or  other  source  of  obstruction 
must  always  be  observed.  Relaxed  and  pouched  states  of  the  pharyngeal  wall, 
notably  at  its  junction  with  the  cesophagus,  oppose  the  progress  of  the  bougie 
not  infrequenlty,  especially  when  the  head  is  not  well  extended.  Deflections 
and  pouches  of  the  cesophagus  may  interfere  with  the  descent  of  the  bougie, 
and  this  interference  should  not  be  opposed  with  vigor,  for  fear  of  causing 
perforation  of  the  tube.  The  partial  withdrawal  of  the  instrument  and 
the  changing  of  its  course  should  be  practiced  promptly  in  this  instance. 
While  cautious  attempts  made  to  dislodge  an  impacted  body  are  always 
admissible,  still  in  the  instance  of  sharp  and  irregular  impacted  agents  the 
manipulations  should  be  much  more  guarded  in  time  and  method  than  when 
such  bodies  are  regular  and  smooth.  It  is  much  safer  to  resort  at  once  to  the 
operative  methods  for  extraction  of  the  obstacle  than  to  prolong  and  aggravate 
the  case  by  renewed  efforts  of  removal  or  by  permitting  the  impacted  body 
to  remain,  especially  when  it  is  contiguous  to  important  structures.  Some- 
times the  instrument  becomes  immovably  engaged  to  a  fixed  obstruction, 
requiring  operative  procedure  for  the  liberation  and  extraction  of  both,  and 
the  situation  will  decide  whether  gastrotomy  or  oesophagotomy  shall  be  per- 
formed. 

The  Remarks. — The  preparation  of  the  walls  of  the  pharynx  for  invasion 
with  instruments,  by  a  weak  solution  of  cocaine,  by  titillation,  the  use  of 
cold,  etc.,  to  arrest  the  spasm,  can  be  practiced  with  discretion.  If  the 
presence  of  a  foreign  body  be  not  noted  with  the  downward  passage  of  the 
bougie,  the  latter  should  be  withdrawn  to  the  upper  end  of  the  tube  and  the 
attempt  repeated,  unless  disclosure  attends  the  withdrawal.  It  should  not 
be  forgotten  that  the  presence  of  the  foreign  body  may  escape  detection, 
and  that  it  may  cause  death  from  perforation  of  the  large  vessels,  heart,  or 
pleura,  without  the  occurrence  of   any  significant  premonitory  symptoms. 


(»ri;i;Ai'i()Ns  ox  'riih;  (Ivsoi'iiaol's. 


595 


III  childrcMi  it  is  \vis(i  to  t'lnploy  an  iiiiifstlietic,  as  better  control  of  tlicni  is 
thus  inaiiitaiiu'd  ;  in  adults  some  assistance  may  bo  rendered  by  tlie  sullerer, 
if  not  ana  sttulizt'ii.  (ienerally  speaking,  bristle  i)roban<,'s  aiul  coin  catchers 
are  used  for  tiu'  extraction  of  smaller,  less  lixed,  and  more  distant  bodies  than 
those  treated  with  the  forceps. 

MdHij  in  (/en  ions  plans  of  action  far  I  In-  rcmnral  of  special  ubstrtidions 
have  been  devised  and  operated  with  success.  Those  for  the  removal  of 
tish  hooks  and  of  pronged  bodies  swallowed  with  string  attachments  will 
sutVice  as  examj)les  of  successful  attempt,  and  are  fertile  with  suggestion  for 
future  action.  The  lino  attached  to  the  hook  is  passed  through  either  a  bullet 
or  some  other  solid  substance,  or  through  a  long,  hollow  bougie.  In  the 
former  instance  the  weight  of  the  bullet  and  the  force  of  the  effort  at  swallow- 


;.  7(i|. —  Iii-l  riiiiiciil^  fiiipl^ycd   in  ii'-Diilumiiii.iiiy. 

a.  Scalpels,  b.  Hetnict<irs.  r.  Forciprcssuro.  d.  .Mouse-tooth  forceps,  e.  Tongue  for- 
ceps and  forceps  for  extraction  of  foreiijn  body.  /.  Goodwillie's  mouth  gag.  g.  Curved 
scissor.s.  /(.  (Esophageal  bougie.  Drainage  tube,  wipers,  ligatures,  traction  loops,  etc., 
are  essential. 


ing  dislodge  the  hook  ;  in  the  latter,  when  the  lower  end  of  the  bougie  reaches 
the  hook,  it  disengages  it  by  direct  downward  pressure  (.Mackenzie). 

The  swallowing  of  a  sticky  bolus  containing  strong  thread  with  a  string 
attached,  and  the  entangling  of  the  foreign  body  thereby  and  its  withdrawal 


44 


596 


OPERATIVE   SURGERY. 


along  with  the   thread,  often   affords  a  liappy  solution   of    the   difficulty 
(Crequy). 

If  a  foreign  body  be  immovably  lodged  in  the  oesophagus  it  must  soon  be 
taken  away  through  an  external  incision,  or  a  fatal  result  will  ensue,  due  to 
ulceration  or  extravasation,  or  perhaps  to  starvation  alone. 

The  oesophagus  can  he  entered  for  this  purpose  from  without  through  the 
7ieck,  the  thorax,  or  the  stomach,  depending  on  the  situation  of  the  ob- 
struction. 

(Esophagotomy. — The  operation  of  oesophagotomy  is  practiced  for  the 
removal  of  obstructions  in  the  cervical  and  upper  dorsal  portions  of  the 
oesophagus,  commonly  caused  by  the  lodgment  of  foreign  bodies. 

The  situation  of  the  foreign  body  in  the  cervical  region  is  usually  deter- 
mined by  the  presence  of  a  prominence  at  the  left  side  below  the  cricoid 
cartilage  ;  or,  if  this  be  not  manifest,  the  exact  site  of  lodgment  in  the  canal 
can  be  determined  by  the  introduction  into  it  through  the  pharynx,  of  a 
good-sized  bulbous  or  other  form  of  bougie  (Fig.  704,  h). 

The  important  surgical  relations  of  the  oesophagus  in  the  cervical  region 
are :  In  front,  with  the  trachea  above  and  with  the  thoracic  duct  and  the 
thyroid  gland  below ;  behind,  with  the  vertebral  column  and  longus-colli 
muscles ;  at  the  sides,  especially  the  left,  with  the  common  carotid  and 
inferior  thyroid  arteries  and  thyroid  lobes.  The  recurrent  laryngeal  nerves 
lie  between  the  oesophagus  and  the  trachea  on  the  respective  sides. 

Tlie  Operation  of  Cervical  CEsophagotomy. — After  thorough  aseptic  meas- 
ures employ  an  anaesthetic ;   place  the  patient  on  the  back,  with  the  chest 

and  shoulders  elevated  and  the  head  turned 
to  the  opposite  side ;  feel  for  the  foreign 
body,  and,  if  it  can  be  located,  make  the 
incision  directly  at  that  point. 

If  the  foreign  body  be  not  discernible 
by  touch,  make  an  incision  about  four 
inches  in  length  on  the  left  side,  between 
the  steruo-mastoid  muscle  and  the  trachea, 
beginning  at  the  upper  border  of  the  thy- 
roid cartilage  (Fig.  765).  The  platysma 
and  fascia  are  divided  on  a  director ;  the 
borders  of  the  wound  are  separated,  the 
omo-hyoid  is  drawn  outward,  and  the 
sterno-  and  thyro-hyoid  muscles  inward  \ 
this  exposes  the  sheath  of  the  carotid, 
which  vessel  is  drawn  outward  and  retained  •,, 
the  lobe  of  the  thyroid  gland  is  raised  and 
drawn  inward  ;  the  larynx  is  carefully  out- 
lined, drawn  forward,  and  held  while  the 
location  of  the  foreign  body  is  sought  for  ;  if  the  latter  be  not  distinguish- 
able a  bougie  is  introduced  to  mark  the  outline  of  the  tube ;  then  raise 
the  wall  with  mouse-tooth  forceps  or  a  tenaculum,  and  open  it  longi- 
tudinally (Fig.   766)   sufficiently   to  admit  a  good-sized  probe,  care  being 


Fig.  765.- 


-ffisopliagotomy,    primary 
incision. 


OPERATIONS   ON   TIIK   (IISOIMI A(a'S.  5<j7 

taken  to  avoid  the  recurrent  laryngeal  nerve.  The  site  of  the  obstruction 
is  located  by  the  probe  and  the  obstruction  is  removed  with  suitable  for- 
ceps, aided  by  nianij)ulation  from  wiLlKjut,  and  facilitated  by  len<(thening  the 
wsophai^eal  incision  if  necessary.  The  opening  in  the  O'sopliagus  may  be 
closetl  with  two  rows  of  tine  catgut  sutures,  the  inner 
being  apj)lied  to  the  mucous  membrane  only,  if  the 
borders  of  the  incision  have  not  been  injured  by  manipu- 
lation or  impaired  by  the  lodgment  of  the  foreign 
body  ;  if,  however,  eitiier  of  these  conditions  be  pres- 
ent, closure  should  not  be  attemi)ted.  In  no  instance 
is  it  wise  to  close  entirely  the  external  incision,  although 
it  may  be  narrowed  by  suturing  the  upper  portion. 
Antiseptic  gauze  is  packed  lightly  in  and  over  the 
wound,  aiul  confined  in  place  loosely  with  a  gauze 
bandage.     The  aim  must  be  to  keep  the  wound  clean 

and  prevent  extravasation  through  and  inflammation  of      '""      ^     ^:'S"F'nagf>t- 

^  .  *=  oinv,  nnal  nicision. 

the  cervical  tissues. 

The  Fallacies. — The  foreign  body  may  be  mistaken  for  an  eidarged  gland 
on  external  examination.  The  esophagus  may  be  confounded  with  the 
lougus-colli  muscle  at  first ;  however,  a  moment's  examination  will  serve  to 
dispel  the  doubt.  The  respiratory  movements  of  the  oesophagus,  distending 
and  collapsing  alternately,  are  important  aids  in  determining  its  identity. 
It  must  not  be  forgotten  that  the  swelling,  pain,  and  tenderness  elicited 
by  external  examination  of  the  neck  are  not  necessarily  at  the  exact  site  of 
the  agent  causing  them,  and,  too,  that  exploratory  agents  do  not  always 
indicate  the  presence  of  a  foreign  bod3%  The  efforts  at  upward  removal  of  a 
foreign  body  that  has  as  yet  caused  no  significant  damage  in  its  downward 
course  are  often  repulsed  by  oesophageal  peristalsis  to  a  degree  that  renders 
removal  upward  unwise  and  perhaps  impossible,  especially  if  the  object  be 
bulky  and  of  irregular  outline. 

The  Remarhs. — If  the  foreign  body  be  not  located  near  the  opening  in 
the  oesophagus,  the  canal  should  be  explored  upward  and  downward  for  its 
detection.  If  below,  it  may  be  at  the  narrow  part  of  the  wsophagus  located 
opposite  the  fourth  dorsal  vertebra,  from  which  point  it  may  be  removed 
with  the  use  of  properly  constructed  forceps.  During  the  operation  all 
bleeding  points  should  be  controlled  promptly.  The  situation  of  the 
inferior  thyroid  artery,  the  anterior  jugular  vein,  and  the  recurrent 
laryngeal  nerve  should  be  clearly  understood,  and  needless  injury  of  them 
avoided.  With  this  object  in  view  and  to  avoid  the  nerve,  the  incision 
into  the  (esophagus  should  be  made  as  far  posteriorly  as  practicable. 
The  opening  in  the  oesophagus  may  be  dilated  by  the  introduction  of  the 
blades  of  curved  dressing  forceps  or  the  lips  pulled  apart  by  traction  loops 
introduced  through  the  borders  of  the  oesophageal  wound.  If  the  obstruct- 
ing agent  be  accessible  and  fixed  in  place  by  its  irregularities  and  projec- 
tions, these,  or  the  object  itself,  can  be  divided  with  bone  forceps  and  after- 
ward easy  removal  accomplished.  Richardson  has  determined  that  the  index 
finger,  when  introduced  into  the  oesophagus  through  a  low  cervical  incision 


598  OPERATIVE   SURGERY. 

(low  cervical  oesophagotomy),  can  reach  the  arcli  of  the  aorta  and  in  some 
instances  pass  beneath  it,  also  readily  appose  an  index  linger  introduced  from 
below  through  the  stomach.  The  utilization  of  this  method  of  manipula- 
tion serves  an  important  purpose  in  the  dislodgment  of  impacted  bodies  and 
in  the  dilatation  of  strictures.  Not  infrequently  prompt  union  of  the  bor- 
ders of  the  wound  has  resulted  in  immediate  healing;  but  this  course  of 
action  is  not  to  be  regarded  as  wise  except  in  special  instances,  and  then 
under  close  surveillance.  The  insertion  into  the  bottom  of  the  wound  of  a 
small  drainage  tube  is  desirable  in  cases  in  which  too  free  separation  of  the 
tissue  has  occurred,  and  where  free  discharges  are  anticipated.  If  the  tissues 
at  the  seat  of  the  obstruction  are  already  inflamed,  emphysematous,  etc., 
oesophagotomy  should  be  practiced  at  once  and  the  wound  left  open, 
thoroughly  drained  from  the  bottom,  and  lightly  dressed  with  antiseptic 
materials.  AVhen  the  nutrient  enemata  are  not  retained  or  are  insufficient 
for  proper  nutrition,  a  feeding  tube  should  be  introduced  through  the  mouth 
or  nose  into  the  stomach,  and  be  kept  in  place  or  passed  at  intervals  for  a 
time,  as  circumstances  may  demand.  When  illy  borne  at  these  situa- 
tions, the  introduction  through  the  wound  is  advisable.  Ordinarily  the 
operation  of  cervical  oesophagotomy  is  not  a  perplexing  procedure  ;  but 
when  the  neck  is  short  or  fat,  the  vessels  and  thyroid  gland  enlarged,  the 
detection  and  removal  of  the  foreign  body  difficult,  or  the  patient  is  ex- 
hausted, the  operation  often  taxes  the  patience  and  fortitude  of  the  surgeon. 

The  After-treatment. — Keep  the  patient  in  bed  with  the  head  and 
shoulders  raised,  and  the  head  so  confined  that  the  movements  will  not 
disturb  the  relations  of  the  tissues  of  the  wound.  For  the  first  day  or  so 
nourish  the  patient  by  the  bowel,  after  this  by  means  of  the  stomach  tube, 
until  the  oesophageal  wound  is  healed.  In  the  case  of  a  six-year-old  patient 
operated  on  by  the  author,  fluid  food  was  given  by  the  mouth  after  forty- 
eight  hours,  and  the  escape  from  the  wound,  during  the  act  of  swallowing, 
was  reduced  to  a  minimum  by  gentle  pressure  upon  it,  made  with  a  good- 
sized  pledget  of  aseptic  cotton  batting. 

The  Results. — Eighty-two  cases  are  reported,  of  which  nineteen  died, 
but  from  causes  independent  of  the  operation  in  many  instances.  The  rate 
can  be  placed  at  about  twenty-two  per  cent,  which  will  surely  be  lessened  in 
the  future,  if  the  operation  be  done  as  early  as  it  should  be.  Promptness  of 
operative  action  lessens  the  rate  of  mortality,  as  a  death-rate  of  19.5  per  cent 
follows  operations  made  during  the  first  three  days,  and  32.1  per  cent  after 
that  time. 

Silver  reports  one  hundred  and  sixty-five  instances  of  cervical  oesopha- 
gotomy for  the  removal  of  foreign  bodies  since  1870,  in  which  one  hundred 
and  twenty-seven  recovered  and  twenty-eight  died. 

Foreign  bodies  in  the  intrathoracic  portion  of  the  oesophagus  can  be 
located  with  ease  by  a  probang.  If  situated  at  the  upper  portion,  the  removal 
may  be  accomplished  through  a  low  cervical  oesophagotomy  and  with  the 
use  of  long  curved  forceps.  Inasmuch  as  the  (esophagus  is  quite  narrow 
opposite  the  body  of  the  fourth  dorsal  vertebra,  it  is  fair  to  assume  that  the 
lodgment  will  be  at  this  point.     However,  if  below  this  place,  the  difficulty 


OI'IIKA'I'IONS   ON    'I"I1K   (i;S()|'ll.\(a'S.  5{)9 

of  i-fiii()v:il  tliri)iiuli  :i ciTvical  incision  will  l)c  ^rrciilly  iiicrfiiscd,  if  not  iiijide 
iiiipossibk'.  Hilt,  iiiasimich  as  coniparativi'ly  safe  relief  tliroiif(li  tlioracotoriiy 
is  as  yet  fjuite  improhahlc,  pronipt,  caiitioiis,  and  intelligent  elTorts  should  be 
first  employed  sit  upward  leiiioval,  not  suflieiently  prolonged,  however,  to  im- 
pair the  ehanees  of  more  ri<j^orous  methods.  Failinj^  in  tiiese  attempts,  removal 
may  yet  be  attained  tiirongh  the  pcrfuniKince  of  tlioracotomy  or  f/ustro/onit/. 
The  former  met  hod  of  relief  is  fully  described  on  page  1()29  et  saj. 

Gastrotomy.— '/ 7/6'  employmoit  of  gastrolomy  for  the  relief  of  u-sophageal 
obstruction  from  any  cause  is  ingenious  and  usually  elfective.  (See  Instru- 
ments Employed,  page  74U.) 

The  Operation. — An  iucision  is  made  in  the  median  line  between  the 
umbilicus  and  ensiform  cartilage  two  or  three  inches  in  length,  the  anterior 
surface  of  the  stomach  is  drawn  forward  and  opened,  the  left  index  finger  or 
the  hand  is  introduced,  and  the  cardiac  orifice  sougiit  for,  by  directing  the 
index  finger  upward,  backward,  and  to  the  left  opposite  to  a  point  just  outside 
of  the  articulation  of  the  costal  cartilage  of  the  seventh  rib  with  the  sternum. 
From  this  time  forward  either  one  of  two  plans  of  removal  can  be  practiced  : 
1.  The  drawing  upward  into  the  mouth  of  the  foreign  body  by  means  of  a 
sponge  (Bull)  or  other  suitable  entangling  agent  connected  to  a  string  intro- 
duced at  the  cardiac  orifice  tiirough  the  opened  stomach,  and  carried  upward 
beside  the  obstacle  and  out  of  the  mouth  by  means  of  a  small  bougie.  2.  By 
dilatation  of  the  cardiac  orifice  and  the  lower  part  of  the  esophagus  with  the 
index  finger  (Richardson)  or  a  suitable  instrumental  dilator,  and  the  removal 
of  the  foreign  body  downward  by  forceps,  or  by  the  employment  of  the  sponge 
and  string  introduced  in  the  reverse  manner  to  that  already  described. 
Richardson  advises  that  foreign  bodies  located  thirteen  inches  or  more  from 
the  incisor  teeth  be  removed  by  the  latter  plan. 

Tlie  Precautious. — The  removal  of  foreign  bodies  from  the  oesophagus 
through  the  stomach  should  be  conducted  with  great  care  and  infinite 
patience  by  means  of  forceps,  supplemented  with  dilatation  of  the  opening, 
and  downward  pressure  by  way  of  the  mouth,  combined  with  dextrous 
handling  of  the  obstructing  body.  Rapid,  forcible,  and  illogical  attempts 
at  withdrawal  cause  lacerations  and  perforations  of  the  oesophagus,  followed 
by  the  unfortunate  sequelae  which  such  procedures  invite. 

77ie  Comments. — The  size  of  the  abdominal  and  of  the  gastric  incision 
is  regulated  by  the  necessity  of  the  case,  which  necessity  should  be  promptly 
recognized  in  order  to  facilitate  the  operation  and  lessen  the  danger.  Be- 
fore the  incision  is  made  into  the  stomach  careful  packing  around  the  organ 
at  the  borders  of  the  abdominal  wound  should  be  practiced  to  obviate  peri- 
toneal infection.  Forcible  manipulations  in  the  extraction  of  foreign  bodies, 
or  in  extended  digital  exploration  of  the  stomach  or  the  oesophagus  carried 
on  through  inadequate  incisions,  are  often  needlessly  prolonged  and  are  harm- 
ful. When  the  size  and  mobility  of  the  stomach  will  permit  it  should  be 
extensively  drawn  through  the  abdominal  opening  before  being  incised  or 
explored  (Fig.  767).  Transverse  openings  into  the  stomach  cause  less  haem- 
orrhage than  longitudinal  ones;  but  extensive  longitudinal  incisions  made 
midway  between  the  greater  and  lesser  curvatures  do  not,  for  anatomical 


600 


OPERATIVE  SURGERY. 


reasons,  cause  dangerous  hasmorrhage.  In  digital  and  instrumental  explora- 
tions the  gastric  incisions  are  made  comparatively  small  and  located  so  as 
to  shorten  the  route  to  the  objective  point.  In  digital  exploration  of  the 
stomach  it  is  difficult  indeed  sometimes  to  locate  with  the  fingers  the  site  of 


Fig.  767. — Delivery  of  stomach  and  introduction  of  forceps. 

the  oesophageal  opening,  because  of  its  obliteration  due  to  contraction  of  the 
walls  of  the  stomach,  provoked  no  doubt  by  the  presence  of  the  finger. 
However,  if  the  finger  be  pressed  cautiously  for  a  time  at  the  site  of  the 
opening  relaxation  will  take  place  and  the  end  of  the  finger  will  readily 
enter  the  tube.  Downward  traction  on  the  stomach  attended  with  flexion 
of  the  cervical  and  dor.sal  portions  of  the  spine  render  the  cardiac  opening 
more  accessible  to  manipulation.  The  putting  of  the  lesser  curvature  on 
the  stretch  by  downward  traction  on  the  stomach  enables  one  to  readily  pass 
a  bougie  along  the  curvature  into  the  cardiac  oi^ening,  e.specially  if  the  gastric 
incision  be  located  well  to  the  right. 

Stricture  of  the  (Esophagus. — For  the  jourpose  of  consideration,  stric- 
ture of  the  oesophagus  will  be  classified  as  malignant  and  non-malignant,  and 
although  either  may  be  treated  by  dilatafion,  divulsion,  external  or  internal 
division,  or  tuhage,  it  will  appear  that  a  diversity  of  modes  of  treatment 
is  better.  In  the  oesophagus  as  in  the  urethra,  the  first  indication  consists 
in  locating  the  seat  of  the  stricture,  after  which  the  treatment  suited  best 
for  the  case  is  carried  into  effect.  Sometimes  supplemental  steps,  such 
as  opening  the  stomach  or  (esophagus,  are  needed  to  bring  the  stricture 
within  the  proper  reach  of  the  curative  manipulations.  Bulbous  bougies 
(Fig.  76?)  are  the  common  diagnostic  agents  employed.  The  fluoroscope, 
when  used  in  connection  with  a  metallic  bougie  or  with  any  shadow-cast- 
ing substance  introduced  into  the  oesophagus,  affords  an  excellent  means 
of  locating  a  stricture  and  of  computing  its  relations  to  contiguous  bone 
structures. 

Dilatation  is  the  simplest  and  safest  method  of  practice  in  non-malig- 
nant stricture.  Direct  and  retrograde  dilatation  are  the  methods  employed. 
The  variou.sly  formed  and  sized  bougies  are  utilized  for  the  purpose,  and 
the  finest  filiform  variety  may  fail  to  pass.  The  size  should  be  increased 
from  time  to  time,  and  when  directly  used,  the  instrument  should  be  intro- 
duced in  the  manner  already  described  (page  59.3). 


OI'KKATIONS   OX   TIIK   (i;S()I'lIA<iL'S. 


Coi 


Tlio  introduction  is  i)riu;ticod  once  in  twu  or  three  days,  according  to  tlio 
clmracteristics  of  tlie  constriction.  The  possibility  of  the  presence  of  aneu- 
risinal  constriction  of  the  tiil)e  shouUl  be  eliminated  before  an  uttonipt  is 
made  to  overcome  the  obstruction. 

Retrof/nide  Dihtfaiion. —  Iletrograde  dilatation  is  directed  to  the  treat- 
ment of  stricture  of  the  lower  portion  of  the  o'soi)hagns  by  way  of  an  open- 
ing throu<,'h  the  stomach  (gastrotoniy),  made  as  for  the  removal  of  foreign 


Fig.  768. — Instruments  employed    in  treatment  of  stricture  of  the  a-SHpliJirii-. 
Whalebone   bougie,   bulbs   of  assorted    sizes.      h.   Sands's   a?sophasotoine,   bulbs  of 
assorted  sizes,     c,  d.  Bullions  and  pointed  bougies,     e.  Bougie  with  string  attach- 
ment.   /.  String  for  friction  purposes.     Bougies  of  various  materials  and  of  assorted 
sizes  are  for  sale. 


bodies,  or  through  the  fistula  of  gastrostomy,  as  the  nature  of  the  case  shall 
determine.  And  in  neither  instance  should  the  opening  into  the  stomach 
be  so  small  or  so  placed  as  to  interfere  with  ready  approach  to  the  cardiac 


602  OPERATIVE   SURGERY. 

orifice.  Diltitation  may  be  produced  by  the  finger  or  by  any  of  the  stereo- 
typed urethral  or  uterine  dihitors  of  suitable  size  and  shape ;  also  sponge 
tents,  laminaria,  and  conical  metal-capped  bougies  with  string  attachment 
are  utilized  for  the  purpose.  Various  devices  for  the  primary  introduction 
of  a  dilating  agent  are  employed.  The  swallowing  of  a  shot  attached  to  a 
string  (Socin)  in  advance  of  opening  the  stomach,  and  the  jiulling  of  the 
shotted  end  through  the  gastric  opening  to  secure  the  return  of  a  bougie  or 
friction  string,  is  an  ingenious  and  effective  measure. 

By  this  means,  too,  Knott's  conical  bougies,  and  laminaria  of  increas- 
ing sizes,  may  be  drawn  upward,  thus  diluting  the  stricture.  It  is  some- 
times difficult  to  locate  the  cardiac  aperture  after  opening  the  stomach, 
because  of  the  obliteration  of  the  orifice.  The  localization  of  it  with  the 
finger  or  with  a  bougie,  as  already  described  (page  600),  may  be  prac- 
ticed. The  introduction  of  an  endoscope  along  a  string  passed  down 
from  above  (Silver),  or  of  a  tunneled  catheter  may  suffice.  Direct  obser- 
vation through  the  endoscope  at  the  seat  of  the  opening  may  detect 
the  entrance  to  the  stomach  from  above  of  fluid  swallowed  for  the  pur- 
pose (Lange).  Other  ingenious  devices  can  be  named,  but  sufficient  is  noted 
already  to  invite  the  exercise  of  discreet  and  fertile  judgment  in  this 
regard. 

Divulsion. — Divulsion  of  an  obstruction  is  not  as  safe  a  procedure  as 
dilatation.  However,  in  the  case  of  failure  of  the  latter,  divulsion  can  be 
carefully  practiced  when  necessary,  in  the  absence  of  other  means  of  treat- 
ment. Direct  and  retrograde  divulsion  are  employed.  The  former  consists 
in  the  introduction  through  the  stricture  in  prompt  succession  of  two  or 
more  oesophageal  bougies  of  graded  size,  with  sufficient  vigor  to  rupture  in 
a  minor  degree  the  contracted  tissues  of  the  obstruction.  The  latter  is  prac- 
ticed in  a  rapid  and  forcible  manner  through  an  opening  into  the  stomach 
by  the  agents  employed  in  dilatation. 

The  immediate  results  are  quite  satisfactory,  and  the  patency  of  the 
tube  may  be  maintained  thereafter  by  the  continued  introduction  of  bou- 
gies by  the  direct  method.  External  division  or  external  oesophagotomy  has 
been  considered  already  (page  596).  Strictures  of  the  cervical  portion  of  the 
CBSophagus  may  be  divided  from  without.  The  stricture  is  first  located  by  a 
bougie  introduced  into  the  tube,  and  is  then  cut  down  upon  through  an  ex- 
ternal incision  as  in  oesophagotomy. 

Internal  G^lsophagotomy  (Internal  division). — Internal  oesophagotomy 
consists  in  the  division  of  the  constricting  tissue  after  the  manner  of  ure- 
thral practice,  with  enlarged  patterns  of  the  instruments  employed  in  in- 
ternal urethrotomy  (Fig.  768,  h).  An  instrument  arranged  so  as  to  be  passed 
upon  a  guide,  as  in  internal  urethrotomy,  has  been  successfully  employed  on 
several  occasions  in  internal  cesophagotomy.  However,  the  contiguity  of 
important  anatomical  structures,  and  the  inability  to  comprehend  the  exact 
relations  of  the  stricture  to  the  outer  wall  of  the  tube,  make  the  operation 
an  exceedingly  hazardous  one.  If  it  be  attempted,  the  constriction  should 
be  incised  only  sufficiently  to  admit  a  bougie,  by  means  of  which  dilatation 
should  be  subsequently  practiced. 


(ii'iiijA'i'io.Ns  (»\  'I'm:  (i:s(>i'iiA(ii's. 


603 


The  liVsuUs. —  III   iiiiu'ti'cii  cases  of  iiilciiial  (r'.sopliupfotoniy  treated    by 
incision,  one  tliini  dicil   in  sixteen  davs   fi-.nu    results  associated  with  the 


Fio.  769. — Abbe's  string  friction  method;  string  escaping  through  a  low  cervical  cesoph- 
agotomy  instead  of  tlirough  the  mouth. 

operation.  Of  the  remainder,  tliree  are  said  to  have  recovered,  wliile  the 
others  survived  for  a  period  from  one  month  to  several  years.  About  one 
third  of  the  cases  required  one  or  more  repetitions  of 
the  operation. 

The  division  of  the  stricture  hy  means  of  string 
friction,  as  devised  by  Abbe  and  practiced  by  him- 
self and  others,  is  a  decided  advance  along  the  line 
of  safety  in  the  treatment  of  stricture  of  the  oesopha- 
gus. The  stomach  is  opened  sufficiently  to  admit 
two  fingers,  along  which  as  a  guide,  a  bougie  carrying 
a  long  silk  thread  is  passed  up  the  oesophagus  and  out 
of  the  mouth  (Fig.  769).  The  lower  end  of  the  string 
is  seized  and  the  stricture  made  tense  by  the  introduc- 
tion of  a  conical  bougie  (Fig.  770) ;  after  which  the 
upper  end  of  the  string  is  grasped  and  carried  well 
back  into  the  pharynx,  while  the  lower  end  is  carried 
into  the  stomach  ;  then  the  string  is  drawn  tight 
and  moved  rapidly  i;pward  and  downward  several 
times  until  the  constricting  bougie  is  released.  This 
bougie  is  removed  and  the  tension  at  the  site  of  con- 
striction renewed  by  the  introduction  of  a  larger  one, 
and  so  on  until  the  esophageal  tube  is  permeable  or 
firm  resistance  is  encountered  by  the  string.  As 
soon  as  a  suitable  sized  bougie  can  be  passed  by  the 
mouth,  the  operation  is  discontinued,  the  string  is 
removed,  the  abdominal  openings  are  closed,  and 
thereafter  bougies  are  introduced  at  regular  inter- 
vals until  all  fear  of  closure  ceases.  It  is  not  fre- 
quent that  the  conditions  require  the  oesophageal  incision,  only,  in  fact, 
when    the    manipulations   through    other  channels   are   futile,   insufficient, 


Fig. 


770.— Making 
the  stricture. 


tense 


604 


OPERATIVE  SURGERY. 


Fig.  771. 

String  friction  emploj-ed 

through  mouth  only. 


or  needlessly  dangerous  to  the  patient.  The  author  suggested  not  long 
since  the  employment  of  string  friction  through  the  mouth  alone  in  the 
following  manner:  Introduce  a  long,  firm,  silken  thread  through  an  open- 
ing made  transversely  at  the  advancing  end  of  a  bougie  (Fig.  7G8,  e).  In- 
troduce the  bougie  through  the  mouth  into  the  grasp 
of  the  stricture  (Fig.  771),  then  seizing  the  ends  of 
the  thread  make  the  rapid  sawing  motion  while  press- 
ing downward  upon  the  bougie,  the 
thread  being  thus  made  to  move  to  and 
fro  through  the  hole  in  the  end  of  the 
bougie  as  over  a  pulley.  The  connec- 
tion to  the  advancing  end  of  the  bougie 
of  a  small  adjustable  wheel  (Fig.  772,  a), 
around  which  the  thread  shall  move, 
and  the  passing  of  the  ends  of  the  string 
through  projecting  arms  provided  with 
wheels  (Fig.  772,  b),  facilitate  the  move- 
ments of  the  string.  If  a  hollow  bougie 
be  employed,  the  apparatus  can  be  sim- 
plified by  carrying  the  ends  of  the  string 
into  the  bougie  through  openings  at  the 
lower  part,  and  thence  upward  and  out 
of  the  upper  extremity  sufficiently  far 
to  permit  of  proper  handling.  In  every 
instance  the  bougie  should  be  a  stiif  one, 
and  the  end  should  not  be  carried  far 
into  the  stricture  before  the  string  is 
brought  into  play.  By  this  method  of 
employment  of  the  string  the  time  of 
use  is  much  lessened  and  the  thera- 
peutic effect  greatly  increased.  It  is 
not  impossible,  therefore,  to  reduce  the  stomach  feature  of  the 
operation  if  desired  from  two  steps  to  one,  and  perhaps  in  some 
cases  to  avoid  it  altogether,  by  this  method  of  employment  at 
either  aspect  of  the  obstruction,  of  string  friction. 

The  Comments. — In  the  event  of  failure  to  dilate  the  stric- 
ture by  way  of  the  mouth  the  surgeon  must  supplement  the    , 
effort  by  the  advantages  arising  from  the  performance  of  gas-    ( 
trotomy  or  gastrostomy.     The  enfeebled  condition  of  many  of  ^\^''    ^' 
the  patients  with  oesophageal  stricture  from  lack  of  nourish-        Y\g.  772. 
ment,  and  the  tendency  of  obstinate  strictures  to  relax  after  String  friction 
a  longer  or  shorter  quiescence  of  the  tube,  have  led  to  increased       ^^^P  lance. 
frequency  of  employment  of  the  latter  plan,  in  order  to  permit  of  ample  and 
immediate  nutrition  and  to  afford  the  rest  to  the  oesophagus  essential  to  stric- 
ture relaxation.     Silver  regards  those  cases  characterized  by  impassible  stric- 
ture and  pronounced  regurgitation — the  latter  indicating  decided  pouching  of 
the  oesophagus — as  suitable  for  jDrompt  gastrostomy.     Cancer  of  the  oesopha- 


(>i'i:i;.\i'i()Ns  ON  'I'lii')  (i;s<)i'iiA(a's.  c^r^ 

gns,  especially,  ciills  for  early  relief  by  lliis  method.  'J'iio  opening  into  the 
stoinacih  siiould  be  made  of  siiflieient  size  to  admit  one  or  two  fingers  along 
with  the  necessary  instrument  for  dilatation,  and  be  placed  well  up  on  the 
anterior  surface  to  permit  of  as  easy  access  to  the  cardiac  orifice  as  possible, 
and  also  to  limit  the  danger  of  leakage  during  the  mani])ulation.  The  bor- 
ders of  the  gastric  ojtening  can  be  drawn  apart  by  traction  loops,  to  afTord 
better  observation,  or  they  may  be  drawn  by  the  loops  closely  against  the 
exploring  agent,  thus  lessening  the  danger  of  escape  of  the  contents  of  the 
stomach.  This  opening  may  be  closed  independently  of  the  abdominal  one, 
provided  dilatation  sufficient  to  allow  the  ready  i)assage  of  lluid  food  and  the 
employment  of  bougies  from  above  have  taken  place.  The  dilatation  should 
be  completed  at  a  single  sitting,  if  possible.  If  preliminary  gastrostomy  be 
performed,  it  is  safer,  other  things  being  equal,  that  two  sittings  be  given  to 
the  operation  than  that  it  be  completed  at  one. 

The  Aftor-tre(ttmc))t. — The  ])assage  of  the  largest  bougies  ^practicable  once 
a  week  or  once  a  month,  according  to  the  demands  of  the  case,  supplemented 
with  the  free  use  of  solid  food  and  the  giving  of  exacting  admonitions  re- 
garding the  need  of  surgical  surveillance  for  an  indefinite  time  to  come,  are 
essential  to  final  success. 

The  Eesulfs. — The  results  of  retrograde  dilatation  are  very  satisfactory 
indeed.  AVoolsey  reports  twenty-eight  cases  "  with  no  death  due  to  the 
operation."  To  this  number  Silver  has  added  ten  with  no  change  in  the 
immediate  results  of  the  operation.  The  final  outcome  is  much  enhanced 
indeed  by  prompt  resort  to  opening  of  the  stomach.  A  steady  and  persistent 
loss  of  weight,  due  to  obstruction  in  swallowing,  forbids  temporizing,  and 
demands  prom])t  and  radical  operative  practice. 

Tubage  with  String  Attachment.— This  plan  is  adapted  to  the  treatment 
of  malignant  strictures,  and  is  ])racticed  on  those  patients  in  whom  for  any 
reason  early  gastrostomy  is  not  practicable.  While  it  is  true  that  through 
the  agency  of  tubage  ample  food  may  be  taken  for  a  time,  also  the  saliva 
swallowed,  and  the  objections  to  early  operation  condoned,  still,  the  progress- 
ive nature  of  the  disease  causing  the  obstruction,  the  effect  on  the  disease  of 
pressure,  and  the  dangers  and  annoyances  of  the  introduction  and  retention 
of  the  tubes,  especially  in  the  advanced  stages,  together  with  the  opportunity 
afforded  for  procrastination  of  operative  practice  until  much  too  late  for  fit- 
ting success,  suggest  the  fact  that  tubage,  although  an  ingenious  and  some- 
times temporarily  nseful  means  is,  on  the  whole,  a  measure  of  questionable 
utility.  However,  the  tube  finds  its  most  rational  use  in  cases  nnsuited  for 
operation.  The  method  is  practiced  by  introducing  into  the  stricture  by 
means  of  a  whalebone  conductor  a. funnel-shaped  flexible  gum-elastic  tube 
with  a  string  attached  (Fig.  773,  b)  four  to  six  inches  in  length,  until  the 
funnel  rests  above  on  the  stricture.  The  lower  end  of  the  tube  resembles 
that  of  the  ordinary  catheter,  except  the  eye  is  made  larger  to  permit  the 
free  passage  of  fluid  food.  The  tube  can  remain  in  place  often  from  one  to 
two  months  without  causing  apparent  trouble.  The  string  escapes  through 
the  mouth  and  is  carried  over  the  ear  for  both  security  and  convenience.  It 
should  be  carefully  guarded  to  prevent  premature  withdrawal  of  the  tube 


(JOB 


OPKRATIV^E   SUKGEKY. 


because  of  careless  traction,  and  difficult  removal  oa  account  of  the  breaking 
of  the  string.  Sometimes  coughing  attends  deglutition,  and  then  the  short 
tube  should  be  replaced  by  a  long  one,  which  can  be  easily  extemporized  by 
cutting  obliquely  and  closing  the  end  of  a  suitable  piece  of  red-rubber 
a  tubing,  making  the  eye  about  an 

inch  above  the  end,  and  introduc- 
ing it  through  the  stricture  with 
a  suitable  conductor. 

The  Results. — Of  seventeen 
cases  treated  by  this  method,  nine 
died  from  the  effects  of  the  dis- 
ease, without  obstructed  degluti- 
tion. 

CEsophagectomy. — (Esophagec- 
tomy consists  in  excising  a  portion 
of  the  oesophagus  through  an  in- 
cision made  in  the  same  manner  as 
for  cervical  oesophagotomy  (page 
596)  or  for  thoracotomy,  for  the 
removal  of  a  cancerous  growth. 
In  the  former  the  upper  end  of  the 
lower  portion  of  the  tube  is  raised 
forward  and  united  to  the  wound, 
thereby  forming  an  opening 
through  which  food  may  be  in- 
troduced by  means  of  a  tube.  The 
latter  method  is  noted  under  the 
proper  heading  (page  1046  et  seq.). 
The  Results. — Only  five  or  six 
cases  have  as  yet  been  reported.  In 
two  of  these  life  was  prolonged  for 
months ;  the  remainder  died  soon 
There  is  rea- 
son to  believe  that  life  can  be  pro- 
longed for  a  greater  length  of  time 
by  feeding  through  a  tube  in  the  usual  manner  than  by  this  procedure. 

OEsophagOstomy. — OEsophagostomy  is  employed  to  establish  a  fistulous 
opening  with  the  oesophagus,  below  the  point  of  an  incurable,  impassable 
constriction.  It  provides  for  the  introduction  of  food  into  the  stomach,  and 
serves  as  a  temporary  palliative  measure.  While  its  adoption  obviates  fox  a 
time  at  least  the  performance  of  gastrostomy,  still,  there  is  no  good  reason 
to  believe  that  it  can  be  regarded  in  any  instance  as  the  wiser  procedure. 


Fig.  773.- 
tiibe. 
bougie. 


.Tube  conductor,     h.  Gum-elastic  after  the  operation 
Small  flexible  bougie,     d.  Bulbous 


OI'Kh'ATlOXS   ox    Vise /■:/,' A    CO \ X lU'TIJ I)    WITH    /'/:/.■  17'OXyErM. 

It  is  etnim'utly  wise  before  considering  the  surgical  tretitnient  of  wounds 
and  diseases  of  the  abdominal  viscera,  that  a  brief  statement  be  made  of  tiie 
proper  metliod  of  approach  to  the  abdominal  cavity  itself. 

Abdominal  Section,  or  Coeliotomy. — Abdominal  section  is  the  opening 
of  the  abdominal  cavity  for  the  pui'pose  of  considering  any  of  the  various 
structures  or  pathological  changes  that  may  be  present  within.  The  situa- 
tion of  the  incision  will  depend  on  the  object  in  view  and  the  importance 
of  the  tissues  involved,  the  length  will  depend  on  the  thickness  of  the  wall, 
the  desired  freedom  of  manipulation,  the  character  of  the  tissues,  and  the 
seat  of  the  division. 

The  Anatomical  Points. — The  bony  landmarks  that  skirt  the  abdominal 
wall  are  each  important,  and  their  individual  significance  should  be  well 
understood.  The  external  oblique  muscle  is  aponeurotic  below  a  line  extend- 
ing between  the  anterior  superior  spines  of  the  ilia,  a  fact  which  if  unknown 
may  lead  to  confusion  in  the  identification  of  the  respective  tissues.  The 
linea  alba  is  broad  above  the  umbilicus  (Fig.  770)  and  narrow  below  (Fig. 
777).  The  borders  of  one  or  both  recti  muscles  are  usually  exposed  in  a 
median  incision  below  the  umbilicus.  The  pyramidalis  muscle  may  be  ab- 
sent on  one  or  both  sides,  double  on  one  and  absent  on  the  other,  and  often 
greatly  developed  on  either  or  both  sides.  The  notch  at  the  upper  border 
of  the  pubic  junction  is  the  bony  guide  to  the  median  line  at  that  situation 
in  the  normal  pelvis.  The  linea  semilunaris  lies  at  the  outer  border  of  the 
rectus  abdominis,  and  extends  in  a  curved  direction  from  the  tip  of  the  ninth 
costal  cartilage  to  the  spine  of  the  pubis,  and  opposite  the  umbilicus  it  is  usu- 
ally about  three  inches  from  the  median  line  in  the  normal  adult  abdomen. 
However,  if  the  cavity  be  distended,  the  distance  is  increased,  as  also  are  the 
width  of  the  linea  alba  and  the  space  between  the  recti  below  the  umbilicus. 
The  differences  in  direction  of  the  fibers  of  muscles  composing  the  abdominal 
wall  and  the  presence  of  associated  fascine,  the  opacity  and  density  of  the 
fascia  transversalis,  the  loose  fatty  texture  of  the  subserous  tissue,  and,  if 
normal,  the  translucent  and  vascularized  peritonaeum,  should  each  be  noted 
for  obvious  reasons. 

It  is  a  noteworthy  fact  that  important  anterior  branches  of  the  dorsal 
and  lumbar  nerves  run  obliquely  downward  and  forward  between  the  mus- 
cular planes  of  the  abdomen  which  they  supply,  and  that  their  severance  is 
followed  by  a  greater  or  less  loss  of  power  of  the  muscles  to  which  they  are 

607 


608 


OPERATIVE   SURGERY. 


distributed.  Therefore,  when  possible,  the  abdominal  incision  should  be  so 
directed  as  not  to  expose  the  patient  to  the  hernial  sequels  incident  to  the 
division  of  those  nerves.  Kelly  calls  attention  to  the  presence  in  the  sub- 
cutaneous fat,  at  a  point  of  about  an  inch  above  the  pubis,  of  a  small  trans- 
verse artery ;  also  to  one  or  more  veins  of  considerable  size,  frequently  found 
(80  per  cent)  lying  on  the  peritonaeum,  behind  the  lower  third  of  the  linea 


Fig.  774. — Patient  prepared  for  abdominal  section. 

alba.  The  latter  empty  into  the  vesical  plexus  and  are  denominated  by 
Kelly  "  the  celiotomy  veins."  Each  of  these  vessels  should  be  promptly 
and  efficiently  tied,  when  divided,  to  prevent  the  persistent  bleeding  that 
results  from  the  fact  of  their  free  anastomoses. 

The  PrejKiration  of  the  Patient. — The  details  of  the  preparation  of  the 
patient  and  the  preparatory  technique  already  stated  (pages  7  and  99)  should 
be  carried  into  effect  with  scrupulous  care.  The  bladder  and  alimentary 
tract  should  have  been  emptied  some  time  before  the  operation.  Place  the 
patient  on  a  well-drained,  narrow  table  of  convenient  height  and  suitable 
mechanism,  with  the  trunk  and  limbs  outside  the  operation  field  well  pro- 
tected with  warm,  dry,  aseptic  clothing  (Fig.  774).  After  thorough  cleans- 
ing, the  abdomen  is  surrounded  with  antiseptic  towels,  and  the  immediate 
surface  itself  is  covered  with  antiseptic  gauze  until  the  beginning  of  the 
operation  (Figs.  162  and  774). 

The  Operation. — Usually  the  incision  is  made  in  the  median  line  below 
the  umbilicus  (Fig.  963).  The  character  of  the  respective  tissues  is  studied 
as  soon  as  eacli  is  divided,  in  order  to  determine  its  individuality  and  the 
presence  of  the  peritoneal  tissue  at  once  (Fig.  776).  Aimless  manipulation 
and  unnecessary  stretching  of  tissues  should  be  condemned.  Arrest  hfemor- 
rhage,  seize  a  limited  part  of  the  peritonaeum  with  thumb  forceps,  ascertain 
if  it  be  free  from  subjacent  tissue,  then  with  a  knife  or  scissors  snip  the  por- 
tion grasped  close  to  the  point  of  seizure  sufficiently  to  admit  the  entrance 


Ui'KliATlONS   OX    VISCKRA   C0NN1-X"I"KI)   WITH    I'lllil'I'oNyKlM.     fjol) 

of  Jiir  and  tlie  iiitrodiictioii  of  s(;issors  for  the  ])iirj)().su  of  further  division. 
When  iideciUiitely  incised  to  permit,  pass  a  curved  needle  armed  with  a  strong 
silk  tliroad  through  the  entire  thickness  of  each  border  of  the  wound,  and 
tie  the  threads  in  the  form  of  kiops  (Fig.  44).  'I'hese  silken  loops  not  only 
serve  as  traction  loops,  hut  they  also  prevent  the  stripj)iug  and  displacement 
of  the  [)eritona'um  from  tlu^  adjacent  tissues. 

The  Prccaiitioiis. — Notwithstanding  the  fact  that  extreme  cleanliness 
should  be  practiced  in  all  operative  procedures,  in  those  directed  to  the 
serous  surfaces,  the  vigilance  and  forethought  of  the  surgeon  shoidd  be  of 
the  highest  order  to  prevent  the  {)0ssibility  of  infection.     All  matters  relat- 


FiG.  775. — Instruments  emj)loyed  in  abdominal  section. 

a.  Scalpels.  b.  Forcipressnre.  c.  Scissors,  d.  Thumb  forceps,  e.  Needle  forceps. 
/.  Tenaculum,  g.  Blunt  retractor,  h.  Xeedles.  i.  Traction  loop.  _/.  Silkworm  gut. 
k.  Chromicized  catj^ut.     l.  Silver  wire,     m,  n.  Broad  and  hooked  retractors. 


ing  to  the  operating  room  (page  T),  the  preparation  of  the  patient,  of  the 
assistants,  and  of  the  surgeon  himself,  should  be  carefully  considered  and 
made  to  conform  to  the  accepted  standard  of  requirement  of  the  time.  In 
the  event  of  the  presence  of  visitors,  those  coming  in  close  relation  with 
the  patient  should  not  have  been  in  recent  contact  with  infecting  agents  or 


610 


OPERATIVE   SURGERY. 


diseases,  nor  should  they  meddle  with  contiguous  objects.  A  safe  rule  of 
action  is  to  keep  the  hands  in  the  pockets  and  avoid  textile  contact  with 
others  unless  properly  clothed  for  the  purpose. 

The  Remarks. — The  seat  of  the  incision  is  determined  usually  by  the 
location  and  outline  of  the  morbid  process  to  be  treated.  The  length  of  the 
incision  is  a  matter  of  great  importance,  for  if  too  short,  observation  and 


Fig.  7T6. — Arrangement  of  tissues  corresponding  to  the  upper  three  fourths  of  the  rectus 
muscle  (above  the  semilunar  fold  of  Douglas). 


manipulation  by  the  surgeon  are  hindered,  and  the  gravity  of  the  procedure 
is  enhanced  because  of  the  delay  and  damage  arising  from  inadequate  in- 
cision. If  too  large,  needless  exposure  and  escape  of  the  abdominal  contents 
will  happen.  Both  primary  and  exploratory  excisions  should  be  made  short 
at  first,  and  be  increased  thereafter  or  changed  in  direction  as  circumstances 
require.  In  long  incisions  Kelly  prefers  division  through  the  umbilicus, 
avoiding  the  suspensory  ligament.  In  closing  the  wound  in  these  instances 
he  splits  the  umbilical  tissue  at  either  side  to  afford  broader  surfaces  for 
approximation.  Considerable  time  is  taken  by  some  operators  in  entering 
the  abdomen,  owing  not  infrequently  to  a  want  of  confidence  in  their  knowl- 
edge of  anatomy  and  the  fear  of  a  precipitous  entrance  into  the  cavity.  If, 
however,  the  primary  incision  be  accurately  located,  and  the  sttcceeding  tis- 
sues be  divided  directly  downward  in  the  same  line,  the  deeper  fasciae  and 
the  peritoneum  being  in  turn  picked  up  at  either  side  with  forceps  and 
raised,  and  the  division  made  between  the  forceps,  a  prompt  and  safe  en- 
trance is  easily  accomplished.  In  the  instance  of  adhesion  between  the 
parietal  peritonaeum  and  that  of  the  subjacent  viscera  great  caution  must  be 
exercised  to  avoid  cutting  the  latter. 

In  those  cases  in  which  the  contents  of  the  pelvis  and  lower  abdominal 
region  are  to  be  examined  and  treated,  the  elevation  of  the  hips  for  a  minute 
or  so  before  and  during  the  operation  aids  materially  in  the  exposure  of  the 
parts,  causing  the  intestines  to  retire  upward  toward  the  diaphragm.  A 
further  need  of  their  withdraw'al  may  be  secured  by  the  employment  of 
retaining  pads  of  aseptic  gauze.  If  difficulty  in  breathing  ensue  or  danger 
of  the  spread  of  infecting  agents  be  enhanced  by  reason  of  the  posture,  it 
should  be  employed  only  with  caution  and  in  a  limited  degree.  The  rolling 
of  the  patient  to  one  side,  away  from  the  seat  of  the  disease,  by  means  of 
mechanical  adjustment  of  the  table  or  by  the  hands  alone,  also  favors  exami- 
nation of  the  affected  site.     The  careful  employment  of  broad  retractors 


()l'i:iv.\'l'l(>NS   ON    Vl.s(i:i;.\    CONNKCI'KI)    WITH     I'i:iM'l'(t.\.i;i  .M.     (ill 

and  tlic  use  uf  a  strung  natural  ur  arlilicial  li;,'lit  are  essential  to  the  attain- 
ment of  intelligent  and  eflicient  observation  and  treatment. 

AdJiesiuiis  are  treated  accoi-ding  to  tlieir  density,  lengtli,  vaseularity,  and 
the  nature  of  the  adherent  surfaces,  etc.  If  fragile,  they  may  he  readily  torn 
by  the  finger  or  a  sponge;  if  dense,  they  should  be  cut;  if  vascular,  they 
should  be  tied  before  or  after  cutting,  according  to  the  size  of  the  adhesion 
and  of  the  bleeding  p<jint.  The  actual  cautery  may  meet  the  indication,  in 
some  instances,  of  persistent  oozing  that  resists  s])onge  pressure,  but  the  cau- 
tery ought  to  be  used  sparingly  on  account  of  its  devitalizing  influence. 
Strongly  adherent  parts  of  non-malignant  growths  may  be  left  attached  to 
an  ini})()i'tant  viscus,  esj)ecially  after  the  adherent  part  has  been  reduced  to 
a  minimum  by  careful  cutting  or  scraping.  The  serous  covering  of  viscera, 
especially  of  the  intestines,  stomach,  etc.,  should  be  treated  with  great  care, 
otherwise  this  membrane  will  be  strij)ped  off,  possibly  destroying  the  nutri- 
tion of  the  wall  at  a  circumscribed  point,  thus  causing  a  slough,  followed 
by  peritonitis  and  death,  or  a  persistent  fistula.  Surfaces  thus  exposed  may 
be  repaired  with  omental  grafts  or  inversion  and  union  of  the  serous  bor- 
ders with  sutures.  Adhesions  maybe  so  dense  as  to  be  irremediable.  Omen- 
tal adhesions  can  be  readily  stripped  or  tied  off  as  their  condition  suggests. 

The  Preccmtions. — In  omental  oozing  it  is  a  quicker  and  securer  method 
of  practice  to  ligature  and  remove  the  omentum  containing  the  bleeding 
area  at  once  than  to  catch  and  tie  separately  the  bleeding  points.  Adhe- 
sions should  be  dealt  with  nnder  direct  observation  when  possible,  in  order 
to  note  the  presence  of  any  ill  effect  from  their  rupture.  It  will  be  neces- 
sary for  this  purpose,  in  many  instances,  to  spread  out  the  adherent  mass  as 
much  as  possible  before  attempting  the  separation,  which  can  then  be  done 
safely  with  scissors  in  the  instance  of  fibrous  bands, 

Ilwmorrhage. — The  occurrence  of  persistent  bleeding  before  or  after  the 
closure  of  the  abdominal  wound  are  often  complications  of  profound  signifi- 


FiG.  777. — Ari:i!ii;einent  of  the  tissues  corresponding  to  the  lower  fourth  of  the  rectus 
muscle  (below  the  semilunar  fold  of  Douglas). 


cance,  especially  the  latter.  If  all  bleeding  points  be  tied  at  once  and  oozing 
be  arrested  the  dangers  of  this  complication  are  reduced  to  a  minimum,  it 
is  wise  to  restore  the  patient  to  the  normal  dorsal  position,  and  perhaps  to 
permit  the  return  of  the  viscera  to  their  normal  relations  in  order  that  the 
influences  of  posture  and  warmth  on  their  circulation  may  be  estimated,  and 
that  any  threatening  outlook  may  be  anticipated  and  remedied  before  the 
45 


612  OPERATIVE  SURGERY. 

final  closure  of  the  abdominal  wound.  If  hfemorrhage  happen  afterward, 
prompt  exposure  of  the  field  of  operation,  removal  of  the  blood  clots,  and 
arrest  of  hemorrhage  is  indicated.  In  such  cases  as  these  indecision  and 
contentment  on  the  part  of  the  medical  attendant  contribute  greatly  to  fatal 
issues. 

The  Cleansing  of  the  Peritoneal  Cavity.— ^\oo([,  urine,  bile,  fecal  matter, 
diseased  and  septic  products,  etc.,  should  be  removed  from  the  peritoneal 
cavity,  when  possible,  with  scrupulous  care.  While  a  considerable  amount  of 
blbod  may  be  absorbed  and  prove  harmless  under  favorable  circumstances, 
yet  even  the  smallest  amount  may  become  the  source  of  septic  infection, 
especially  if  infecting  influences  be  already  present  in  the  abdominal  cavity. 
Flushing,  wiping,  and  drainage,  are  the  common  expedients  employed  for 
cleansing  purposes.  An  abundance  of  the  hot  saline  solution  (six  tenths  of 
one  per  cent) ;  a  weak  solution  (1  to  10,000)  of  corrosive  sublimate  or  of 
carbolic  acid  (1  to  100);  Thiersch's  fluid;  hot  sterilized  water,  etc.,  have 
each  been  used  for  the  purpose  of  flushing.  However,  the  employment  of 
the  bichloride,  carbolic  acid,  and  similar  solutions,  is  regarded  with  much 
less  favor  now  than  formerly,  because  of  the  proved  deleterious  effect  exer- 
cised by  them  on  the  serous  membrane,  an  effect  that  renders  the  membrane 
more  vulnerable  to  septic  influences.  Latterly  the  hot  saline  solution  has 
been  generally  employed  for  this  purpose,  not  only  because  it  is  harmless  jyer 
se,  but  also  because  it  combats  infection  directly  by  its  osmotic  properties. 
General  flushing  should  not  be  practiced  for  circumscribed  infection,  since 
this  infection  can  be  well  treated  by  wiping  and  local  flushing  ;  and,  too,  the 
former  plan  of  action  will  cause  the  dissemination  of  the  infective  material. 
General  flushing  must  be  practiced  with  great  discretion  and  with  reference 
to  the  demands  of  individual  cases,  for,  as  Treves  wisely  remarks, "  It  is  quite 
as  possible  to  do  too  much  as  to  do  too  little."  In  general  flushing,  the  bor- 
ders of  the  wound  are  held  upward  and  apart,  and  the  fluid  is  poured  freely 
into  the  cavity  and  allowed  to  flow  out  unhindered  until  it  escapes  un- 
changed in  appearance.  The  cleansing  effect  of  the  fluid  can  be  increased 
by  agitating  the  abdominal  contents  with  the  hand,  supplemented  with  alter- 
nating brisk  pressure  upon,  or  shaking  of,  the  contents  by  external  manipu- 
lation. If  the  patient  be  then  turned  to  one  side  and  held  there  cautiously 
for  a  brief  time,  nearly  all  of  the  fluid  will  escape.  Finally,  the  portion  re- 
maining is  caused  to  gravitate  into  the  pelvis  by  raising  the  body  upward  to 
a  proper  angle  and  retaining  it  there  while  the  fluid  is  removed  as  fast  as  it 
collects  by  careful  sponging  or  siphonage.  In  so  doing  it  is  wiser  to  intro- 
duce a  large  sponge,  which  is  removed  as  soon  as  it  is  well  filled,  squeezed, 
and  again  returned,  as  less  friction  will  attend  this  plan  than  that  of  the 
repeated  introduction  of  small  sponges. 

If  infectious  extravasation  have  occurred,  the  abdominal  wound  should 
be  made  large  enough  to  afford  prompt  inspection  and  removal  of  the  injuri- 
ous agents,  as  the  hindrance,  delay,  and  imperfect  opportunity  for  action  in 
the  presence  of  a  small  opening  do  much  to  prejudice  the  recovery  of  the 
patient.  In  these  cases  the  intestinal  folds  should  be  raised  and  the  hidden 
recesses  carefully  flushed  to  remove  concealed  infection.     It  should  not  be 


Ul'EKATlUNS   ON    VISCKKA    CONNKC  "IMID    WTIMI    I'lM;  IToNMllM.     r,];', 

forjTfottcn  that  vinrorous  or  repeatc'd  spoii^^Mn;,'  di-  \vi|(iiii,r  with  any  a^'ciit 
ext'irises  a  traiiinatic  clTect  on  a  serous  siirract-,  and,  tlicrefore,  increases 
its  vulnerability  to  sepsis.  Sponging  should  not  be  hastily  or  needlessly  em- 
ployed. It  is  rare,  iiulecd,  in  general  septic  peritonitis  that  general  flushing 
can  be  pn)[)erly  practiced.  The  intestiiuil  distention  in  these  cases  causes 
not  oidy  a  pr()ni])t  protrusion  of  tlie  bowel  through  the  smallest  opening, 
but  it  likewise  obstructs  the  introduction  of  the  lluid  and  prevents  the 
flushing  of  the  infected  surfaces.  We  know  of  no  way  of  accomplishing 
tiiorough  cleansing  in  this  condition  except  it  be  by  the  removal  and  rinsing 
of  the  intestines  outside  of  the  body.  Although  by  a  course  of  this  kind 
the  intestines  and  abdominal  cavity  can  be  thoroughly  cleansed,  still,  the 
return  and  retention  of  the  overdistended  intestines  will  be  practically 
impossible  unless  their  contents  be  discharged  through  free  incisions  at 
isolated  points,  which  are  closed  by  intestinal  suture,  a  line  of  action 
which  should  be  regarded  as  more  vigorous  than  wise  in  the  great  pro- 
portion of  such  cases.  Localized  flvshing  is  easily  accomplished,  owing  to 
the  fact  that  the  infective  influences  can  be  quite  well  circumscribed  by  a 
wall  of  antiseptic  gauze  or  sponges.  In  fact,  the  cautious  surgeon  will 
anticipate  the  escape  and  spread  of  infecting  material  in  many  instances  by 
the  establishment  of  a  i)reliminary  antiseptic  environment. 

The  Cunvuenfs. — The  temperature  of  the  saline  solution  should  be  about 
112"  Fahr.,  and  the  fluid  should  be  poured  carefully  from  a  pitcher  and 
directed  in  the  proper  course  by  the  hand  of  the  operator.  The  use  of 
the  hand  in  this  connection  is  especially  important,  as  the  fingers  can  be 
more  safely  introduced  and  carried  between  the  intestines  than  can  inani- 
mate objects ;  and,  moreover,  an  improper  temperature  of  the  fluid  is  thus 
quickly  noted.  Htill,  the  fluid  can  be  discharged  satisfactorily  into  out-of- 
the-way  places,  through  straight  or  curved  smooth  glass  or  rubber  tubes. 

The  serous  fossre  associated  with  the  caecum,  the  kidneys,  the  beginning 
of  the  jejunum,  the  rectum,  etc.,  need  careful  attention  to  determine  the 
presence  in  them  of  infection,  especially  in  instances  of  extended  contami- 
nation. The  leaving  behind  more  or  less  of  the  saline  fluid  in  the  intestinal 
folds  for  the  purpose  of  facilitating  the  resumption  of  their  normal  func- 
tions and  the  prevention  of  adhesions,  and  thus  obviating  their  prospec- 
tive entanglement,  is  often  advised.  While  it  is  hardly  possible  to  attach 
much  practical  importance  to  this  proposition,  owing  to  the  rapid  absorption 
of  the  fluid,  still  no  harm  need  arise  from  its  presence,  and  much  good  will 
attend  the  absorption  because  of  the  accompanying  abstraction  of  infecting 
agents. 

The  Drainage  of  the  Peritoneal  Cavity. — If  the  surgeon  could  be  assured 
of  the  absence  of  infection  and  of  the  nonproduction  in  the  cavity  of  irri- 
tating products,  drainage  could  be  dispensed  with.  Owing,  however,  to  the 
difficulty  of  removing  entirely  from  the  peritoneal  cavity  the  infectious 
elements  incident  to  the  presence  of  pus,  putrid  fluids,  etc.,  and  the  liability 
of  the  production  of  fluids  from  injured  surfaces  in  excess  of  the  power 
of  absorption,  it  is  wise  to  forestall  possible  disaster  or  subsequent  reopen- 
ing of  the  cavity  by  the  employment  of  adequate  drainage.     If  one  be  in 


f;i4 


Of'KF;.\TfVK    SlliCFAiY. 


doubt  regarding  the  advJHability  of  drainage,  then,  indeed,  it  should  be 
practiced,  as  but  little  harm  can  arise  from  the  proper  use  of  drainage  agents 
as  compared  to  that  resulting  from  its  need,  'i'extile  fabrics  and  rubber 
and  glass  drainage  tubing  are  tlie  agents  in  common  use.  Kubber  and  glass 
tubes  serve  to  collect  the  discharges  rather  than  to  expel  them  from  the 
wound ;  however,  when  thus  collected  the  discharges  are  removed  by  suction 
with  a  small  syringe  armed  with  a  rubber  tube.  Not  infrequently  textile 
fabric  is  introduced  into,  and  sometimes  around,  a  glass  drainage  tube  (Fig. 
778),  thereby  substituting  for  the  syringe  the  influence  of  capillarity,  and 

thus  lessening  the  dangers  of  infection 
from  without.  Since  the  textile  fab- 
ri';   acts  by  capillarity,  its   efficiency 


Fio.  778. — Perforated  glass  tiitje  contairiirif^ 
textile  fabric. 


i.-;  increased  by  a  parallfl  arrangement 
of  its  fibers.  In  itll  instances  the 
drainage  agents  should  be  carried  to 
the  bottom  of  the  most  dependent 
parts,  as  superficial  drainage  alone  is 
both  deceptive  and  ineffectual.  Anti- 
septic candle  wicking  and  gauzes  are 
in  common  use  for  the  purpose.  It 
should  be  emphasized  that  the  packing 
of  a  wound  with  gauze  hinders  rather 
than  facilitates  the  escape  of  the  dis- 
charges; therefore, textile-fabric  drain- 
age should  be  arranged  loosely  and 
carefully  in  as  direct  a  manner  as 
possible  from  the  site  of  beginning  to 
the  external  surface  of  the  body.  This  variety  of  drainage  can  be  in.serted 
between  the  intestinal  folds  in  various  directions.  In  order  that  the  wound 
be  not  infected  from  without  on  account  of  the  drainage  tube,  the  external 
opening  must  be  carefully  closed  with  antiseptic  gauze  or  sponge  during  the 
intervals  of  cleansing.  The  syringe,  too,  should  be  carefully  guarded  against 
contamination.  Ordinarily,  drainage  can  be  dispensed  with  in  two  or  three 
days.  By  this  time,  in  many  cases,  the  intervention  of  fibrinous  products 
caused  by  serous  contact  with  the  drainage  agent  will  have  reduced  the 
efficiency  of  drainage  at  the  original  site  to  a  minimum. 

The  Remarks. — The  absence  of  organisms  in  the  field  of  operation,  as 
determined  at  the  time  by  the  microscope,  should  )>e  regarded  as  contraindi- 
cating  drainage.  Kelly  omits  it  in  gynaecological  cases,  even  in  the  presence 
of  a  small  number  of  germs,  with  satisfactory  outcome.  However,  when 
for  any  reason  the  circulation  of  the  intestines  is  impaired,  interfering  with 
their  powers  of  absorption  and  elimination,  the  employment  of  drainage  is 
advisable,  and  especially  so  in  the  presence  in  the  peritonaeum  of  infect- 
ing agents.  Pieces  of  gauze  fifteen  to  twenty  inches  long  and  two  or  three 
inches  wide,  so  folded,  with  the  edges  inturned  and  sewed,  as  to  prevent  rav- 
eling, are  suitably  constructed  drainage  agents.  These  drains  are  made  of 
plain  or  sterilized  and  principally  of  iodoformized  gauze.    In  the  latter  it  is 


()i'i;i;.\'rii)\s  on  visckua  connI'Ictki)  wi'iii  i'i:i{i'i'()Nj:r.M.    c.i:, 

wise  U)  wash  (tiiL  tlie  excess  of  ioddfcd'ni  witli  stci'ilizcd  water  licforc  intro- 
duction. 

The  latr  Id-.  \aii  Arsdalc  expressed  ;,M-eat  appreciation  of  the  drain  made 
of  phiin  <,Miize  saturated  with  sterilizeil  oil,  ehiiniiiifjf  f(jr  it  a  hi;,d)  decree 
of  absorptive  power,  easy  introtluction,  and  safe  and  comparatively  painless 
removal.  Tiie  surrounding  of  textile-fabric  drains  with  aseptic  perforated 
rubber  tissues  prolongs  their  efllcioncy  and  facilitates  their  removal.  Pieces 
of  this  tissue  loosely  rolled  are  serviceable  drains,  and  are  easily  removed 
because  of  little  adherence  to  the  serous  surfaces.  The  introduction  into  the 
abdomen  of  a  drain  should  be  done  in  a  manner  best  designed  to  facilitate 
draimigo  and  to  favor  easy  and  safe  removal  of  the  drain.  The  aggregate 
of  the  textile  fabric  employed  is  regulated  l)y  the  size  of  the  area  to  be 
draiiu'd  and  the  pr()S[)ective  amount  of  the  discharge.  Packing  tiie  wound 
iiinders  piopci-  drainage  and  ought  not  to  be  done  except  to  control  ha-m- 
orrhage. 

'i'he  drainage  agents  should  extend  from  the  infcctiMl  parts  by  the  short- 
est j)racticable  routes  to  without  the  abdomen.  If  the  infection  be  extensive 
the  number  of  the  drains  should  be  increased  aiul  alhjwed  to  escape  at  dif- 
ferent aspects  of  the  abdomimil  "vall,  usually  at  the  sides.  In  all  instances, 
wiiere  practicable,  dei)endent  drainage  should  be  established.  The  outer 
ends  of  the  drainage  agents  and  the  openings  transmitting  them  are  a  con- 
stant menace  to  asepsis ;  therefore  they  should  be  protected  by  an  abundance 
of  gauze  which  will  at  the  same  time  aid  materially  the  functions  of  the 
drains  themselves.  The  gauze  should  be  changed  as  soon  as  it  is  wet  with 
the  discharges. 

Tlie  Precautions. — Gauze  drains,  especially  the  iodoformized,  should  be 
twisted  quite  vigorously  until  loosened  before  withdrawal  is  attempted,  and 
even  then  it  is  quite  painful.  When  gauze  packing  is  employed  it  should 
be  introduced  first  around  the  outer  border  of  the  bleeding  area,  thence 
toward  its  center,  thus  permitting  of  its  easy  removal  from  the  center  toward 
the  periphery.  This  variety  of  drain  especially  should  not  be  placed  in 
contact  with  the  ligatures  or  lines  of  delicate  sewing,  because  of  its  tena- 
cious adhesion  to  contiguous  structures  and  the  consequent  liability  to 
luemorrhage  and  tearing  on  removal.  Ordinarily  the  need  for  drainage  is 
met  in  two  or  three  days,  when  the  agent  should  be  removed,  for  delay  pro- 
vokes increased  discharge,  exposes  to  infection,  causes  ulceration,  and  lays 
the  foundation  for  sinus  formation,  intestinal  obstruction,  and  hernial  pro- 
trusions. The  threads  liable  to  detachment  from  a  drain  should  be  removed 
and  the  borders  turned  in  and  securely  sewed,  otherwise  they  will  become 
detached  from  the  drain  and  remain  in  the  wound,  causing  abscess,  and  per- 
haps fatal  sepsis. 

The  Closure  of  the  Wound. — A  thin,  wide  sponge  or  broad  gauze  "  wiper  " 
(Fig.  GO)  should  be  placed  on  the  abdominal  contents  before  closing  the 
wound,  to  prevent  the  escape  of  the  intestines  and  absorb  such  fluid  blood  as 
may  come  in  the  way.  Two  methods  of  closure  of  the  borders  of  the  wound 
are  practiced  :  1,  in  which  certain  tissues  are  joined  independently  with  each 
(Fig.  779)  other — i.  c.,  tier  suturing  (Fig.  780) ;  2,  in  which  the  borders  are 


616 


OPERATIVE   SURGERY. 


.>k 


joined  as  a  whole,  sometimes  called  suturing  en  masse  (Fig.  781).  In  the 
former  the  serous  and  fascial  tissues  may  be  united  independently  with  a 
continuous  suture,  then  the  subcutaneous  fat,  and  finally  the  integument  are 

^ ^  similarly  united,  thus  introducing  four  lines  of 

sutures;  the  number  can  be  increased  or  dimin- 
ished as  suits  the  surgeon.  In  the  latter  method 
the  borders  are  transfixed  with  a  long  needle  car- 
ried at  either  side  from  within  outward,  there- 
fore requiring  a  needle  at  each  end  of  the  suture. 
Although  this  plan  of  introduction  is  the  bet- 
ter one,  still,  the  transfixion  is  often  made  from 
right  to  left,  or  the  reverse,  with  a  single  needle, 
the  first  border  being  pierced  from  without  and 
the  last  from  within,  both  including,  perhaps, 
the  peritoneum  of  the  respective  sides.  The 
requisite  number  of  sutures — about  three  fourths 
of  an  inch  apart — should  be  placed  before  any 
are  tied,  unless  the  wound  be  a  long  one  and 
intestinal  protrusion  be  pronounced,  then  one 
or  more  of  the  upper  sutures  should  be  tied  at 
once  to  reduce  the  size  of  the  opening.  The 
final  outcome  of  the  two  methods  of  procedure 
is  of  obvious  importance.  In  the  first  method 
less  than  six  per  cent  experience  hernial  pro- 
trusion ;  in  the  latter  a  greater  number  are  said 
to  suffer  sooner  or  later  from  this  infliction. 

The  Comments. — In  either  method  of  sew- 
ing, room  should  remain,  when  needed,  for  the 
exit  of  the  drainage  agent,  which  is  usually 
placed  at  the  most  dependent  part  of  the  in- 
cision. The  sutures  should  be  tied  from  above  downward,  the  sponge  or 
gauze  being  removed  while  sufficient  room  yet  remains  for  its  exit.  The 
air  within  the  peritoneal  cavity  should  be  expelled  by  pressure  before  com- 
plete apposition  is  made  of  the  peritoneal  borders.  Silkworm-gut,  silver- 
wire,  catgut,  and  silk  sutures  are  used  according  to  the  fancy  of  the  sur- 
geon, the  first  two  being  preferable  in  most  cases  of  heavy  sewing.  A  close 
apposition  with  each  other  of  the  divided  borders  of  the  respective  tissues 
is  essential  to  the  final  security  of  the  line  of  union.  Catgut  sutures  are 
commonly  employed  in  sewing  the  peritoneum  ;  silver  wire  and  chromicized 
catgut  in  sewing  the  fascial  and  aponeurotic  tissues ;  chromicized  catgut  and 
silk  the  muscular;  catgut  the  adipose,  and  silkworm  gut  and  catgut  the 
cutaneous  tissues.  The  mattress  and  subcuticular  sutures  are  suited  to  the 
fascial  and  subcutaneous  structures  respectively. 

The  Precautions.— The  borders  of  the  fascia  retract  considerably  on  divi- 
sion, and  may  therefore  escape  notice  and  remain  ununited,  thus  contribut- 
ing greatly  to  adhesions  and  hernial  sequels.  They  should  be  secured  and 
carefullv  united  with  each  other  in  order  that  firm  union  shall  be  estab- 


FiG.  779. — Tier  suturing. 


OPHKATloNS   (IN    VIS(I:KA    COXN'KCTKK    Willi    I'KIIildN.i:!  M.     ,;|7 


lisht'il.  Tilt'  hkftliii^'  points  of  the  siiljciitaiicoiis  fat  fsiicciiillv  should  be 
looketl  for  and  sivmvlv  aiTL'sted  to  avoid  siiljsi'(|iieiit  How  and  llio  forma- 
tion of  liii'matonia  and  its  sequels. 

The  Tredliiivnl  of  llie  Womul,  <-tt: — Tlie  wound  is  cleansed  and  several 
layers  of  sterilized  gauze,  large  enough  to  extend  four  or  live  inches  heyond 
the  borders  of  the  incision,  are  ap])lied.  Silver-foil  films  are  directly  applied 
and  held  in  place  with  gauze  and  adhesive  strips  in  subcuticular  sewing 
(Ilalstcd).  Abundant  layers  of  sterilized  cotton  or  ''combination"  (page  IJ4) 
are  placed  over  the  primary  dressings.  The  whole  is  conllned  firmly  in  place 
by  means  of  a  single  broad  body  bandage,  or  by  one  of  the  many-tailed  pat- 
tern. In  eitlier  instance  the  lower  borders  will  slip  upward  unless  confined 
by  means  of  perineal  straps.  The  binder  is  a|)plied,  having  an  opening  for 
the  end  of  the  tube,  the  tube  protected,  and  the  patient  placed  in  bed.  Jiot- 
tles  or  other  receptacles  filled  with  hot  water  and  carefully  surrounded  with 
flannel  are  placed  at  tlie  patient's  side  and  between  the  limbs,  if  circum- 
stances demand  their  use. 

lite  After-treatment. — The  patient  is  kept  quiet  on  the  back,  thirst  is 
relieved  with  hot  saline  enemata,  the  bladder  is  emptied  with  a  catheter, 
light  food  is  given,  the  temperature  and  pulse  are  recorded,  and  otherwise 
carefully  watched.  Constipation  is  treated  with  salines  and  enemata,  flatu- 
lence, with  carminatives  and  the  rectal  tube.  Unless  specially  indicated  the 
wound  is  not  dressed  till  the  fifth  or  sixth  day,  and  again  in  two  or  three 
days  thereafter,  at  which  time  the  stitches  are  removed,  and,  if  need  be,  the 
abdomen  is  supported  with  strips  of  adhesive  plaster  and  a  binder.  The 
bodily  comfort  of  the  patient  should  be  considered  from  the  outset  by  en- 
couraging change  of  posture  in  bed,  the  use  of  baths,  and  fresh  linen.  The 
l)atient  is  permitted  to  get  up  at  about  the  end  of  the  fourth  or  fifth  week, 
and  for  some  months  thereafter  an  abdominal  supporter  may  be  worn, 
especially  by  fleshy  patients. 

The  General  Comments. — The  opening  in  the  peritonaeum  should  be 
made  small  at  first,  only  large  enough  perhaps  to  admit  the  index  finger ; 


Fig.  TyO. — Tier  suturing,  transverse  sec- 
tion. 


Fig.  T81. — Suture  en  masse,  peritonieuni 
sutured  independently. 


later,  however,  it  should  be  increased  to  meet  the  demands  of  explorative 
and  operative  technique,  without  unnecessary  delay  or  the  employment  of 
undue  force.  A  large  sponge  introduced  into  the  pelvis,  and  numerous 
small  ones  placed  at  the  borders  of  the  operation  field,  will  absorb  the  fluids 
associated  with  the  operation,  and  additionally  the  latter  should  prevent  the 
escape  of  the  intestines  and  their  contact  with  deleterious  agents.  Injury  to 
the  ureter,  intestine,  gall  bladder,  etc.,  should  be  carefully  avoided,  and  when 
inflicted  prompt  repair  should  be  practiced. 


618  OPERATIVE  SURGERY. 

21ie  Fallacies. — The  aponeurosis  of  the  external  oblique  may  be  mistaken 
for  fascia,  and  consequently  the  internal  for  the  external  oblique,  and  so  on, 
causing  much  anatomical  confusion.  The  transversalis  fascia  may  be  mis- 
taken for  the  peritonaeum,  and,  therefore,  the  subserous  tissue  for  the  omen- 
tum, and  possibly  the  gut  for  the  peritonaeum  itself ;  and  especially  is  the  last 
fallacy  liable  to  present  if  the  intestine  be  adherent  to  the  parietal  peritonaeum. 
The  number  of  the  sponges  and  all  other  agents  employed  in  direct  con- 
nection with  abdominal  section  should  be  accounted  for  before  the  wound 
is  closed,  otherwise  they  may  remain  behind  in  the  cavity  and  lead  to  fatal 
results.  The  bladder  may  be  incised  if  adherent  to  the  wall  or  filled  with 
urine,  hence  it  should  be  emptied,  and,  if  a  doubt  as  to  its  location  arise, 
its  limits  should  be  outlined  with  a  sound  at  the  time  of  operation. 

The  Results. — The  results  will  be  stated  in  connection  with  the  special 
objects  for  which  the  abdominal  section  is  made. 

Explorative  Abdominal  Section,  or  Explorative  Laparotomy.— The  ab- 
dominal cavity  is  frequently  opened  for  the  purpose  of  ascertaining  the 
cause  of  diseased  manifestations,  and  with  the  view  of  applying  the  surgical 
remedy,  therefor,  if  feasible ;  but  if  impracticable,  the  incision  is  usually 
promptly  closed.  The  technique  of  the  explorative  section  differs  in  no 
essential  manner  from  that  already  stated.  The  incision  is  usually  made 
over  the  seat  of  the  trouble. 

OPERATIOXS    ON   THE    INTESTINES. 

It  is  important  in  operations  on  the  intestines  to  observe  the  following 
considerations  with  great  care  :  1.  The  avoidance  of  all  unnecessary  haemor- 
rhage. 2.  The  prevention  of  the  escape  of  irritating  matters  into  the  abdomi- 
nal cavity.  3.  The  union  of  the  divided  borders  so  that  they  will  remain 
properly  joined  and  result  in  perfect  repair.  4.  The  avoidance  of  unnecessary 
shock  and  of  the  retention  of  septic  and  irritating  influences. 

The  first  indication  is  met  by  the  avoidance  of  incisions  through  the 
lines  of  the  established  course  of  vessels,  and  by  the  use  of  needles  which  do 
not  possess  cutting  edges. 

To  meet  the  second  indication  requires  a  great  degree  of  care  irrespec- 
tive of  the  knowledge  of  any  established  measures.  The  lips  of  the  wound 
should  be  cautiously  guarded  by  various  expedients.  If  the  nature  of  the 
case  will  permit,  the  contents  of  the  viscus  should  be  removed  or  pushed 
aside  before  the  incision  is  commenced,  and  at  all  times  the  serous  surfaces 
must  be  protected  from  contact  with  irritating  matters,  by  means  of  broad, 
thin,  aseptic  sponges,  or  pads,  moistened  in  a  warm,  mild,  aseptic  fluid. 

To  fulfill  the  third  indication.,  sutures  of  various  forms  and  methods  of 
application  are  employed,  the  aim  of  all  being  to  bring  the  serous  surfaces 
in  contact,  and  maintain  them  so  until  firm  union  is  established  (Figs.  782 
to  860).  When  possible,  a  wound  of  the  intestine,  however  small,  should  be 
closed,  to  prevent  the  escape  of  irritating  matters  into  the  abdominal  cavity. 

The  fourth  indication  is  very  important,  especially  if  the  operation  be 
prolonged  and  tedious,  or  if  it  be  necessary  to  remove  the  intestines  from 
the  cavity  of  the  abdomen.     The  room  in  which  operations  on  the  abdom- 


OI'KKA'IMoNS   ON    N'ISCKIJA    ('( >N  NIK  "rill)   WI'I'II    I'KKI'roNJ;! '.M.     cp.* 

inal  conti'iits  are  perfunned  .should  he  tli()r()ii<fldy  ck'unsed  and  fiMni«'ated 
when  possible,  iiml  in  every  way  made  aseptic.  If  the  temperature  can  be 
raised  to  about  90°  F.,  and  the  atmosphere  moistened  with  vupor,  the  sur- 
roundings will  be  much  improved,  especially  for  cases  in  which  the  ab- 
dominal contents  are  long  exposeil.  if  the  intestines  be  removed  from  the 
cavity,  they  must  be  surrounded  by  sterile  cloths  saturated  witii  hot  {IVZ°  F.) 
aseptic  fluids,  preferably  the  saline  solution,  and  kept  warm  and  moist  bv 
repeated  applications  of  the  same  until  they  are  replaced.  The  "  toilet  "  of 
the  abdominal  cavity  must  be  cautiously  and  perfectly  made  before  closure, 
and  suitable  provisions  for  drainage  established  if  pernicious  secondary  local 
processes  be  apprehended. 

Intestinal  Sutures. — The  varieties  of  intestinal  suture  are  numerous, 
ingenious,  and  etl'ective,  but  often  too  complicated  to  be  ])racticable  for  the 
use  of  others  than  those  who  designed  them.  Our  aim,  therefore,  will  be  to 
describe  those  only  that  have  the  sanction  of  practicability  established  by 
experienced  use.  Straight  needles  that  displace  and  do  not  cut  the  tissues  in 
the  passing  are  employed  in  intestinal  sewing,  the  common  cambric  needle 
being  a  good  illustration  of  the  kind.  Silk  is  of  accepted  use  in  intestinal 
sewing.  It  should  be  of  sufficient  strength  to  permit  of  proper  apposition 
of  the  surfaces,  and  colored  to  enable  the  operator  to  define  easily  the  exact 
location  of  the  sutures.  The  fine  iron-dyed,  twisted  kind  is  very  satisfac- 
tory in  these  respects.  Fine  catgut  is  sometimes  used  instead  of  silk,  but  is 
much  less  reliable.  Stronger  and  coarser  silk  than  the  preceding  is  em- 
ployed in  common  sewing  and  in  the  ligature  of  vessels.  A  still  greater 
increase  in  these  characteristics  is  needed  in  the  ligatures  applied  to  large 
masses  of  tissue,  pedicles,  etc.  The  braided  and  cable-twist  varieties  are  the 
strongest,  the  latter  being  of  American  and  English  manufacture,  and  the 
former  of  these  is  the  weaker  of  the  two.     It  is  to  be  regretted  that  the 


Fig.  782.— The  continu- 
ous suture. 


Fig.  783. — The  Gely  suture,  external  appearance. 


standards  of  size  of  silk  are  not  so  definitely  classed  as  are  those  of  wire,  for 
then  silk  could  be  ordered  with  a  certainty  of  return  that  now  can  be  secured 
only  by  the  sending  of  a  sample  of  the  required  size. 


620 


OPERATIVE  SUEGERY. 


Fig.  784. — The  Gely  suture,  internal  appearance. 


U)-h- 


ss:  ^f^  ^^  -m^  ^^^  ^^^  ^^  ^^^  ^s^  ^^  sssteEE  232= . 


cl    e  h  i 


The  Precmdions. — Unless  the  strength  of  silk  be  tested  before  it  is  used 
it  may  break  when  applied,  causing  delay  and  confusion  and  perhaps  impair- 
ing the  work  of  the  surgeon.  Su- 
tures, especially  of  silk,  passing 
unhindered  through  the  mucous 
and  serous  surfaces  of  intestines 
are  liable  to  infect  the  latter  sur- 
face by  capillarity.  Hence  the 
sutures  should  include  the  serous, 
muscular,  and  submucous  fibrous 
coats,  the  mucous  being  omitted 
in  all  instances  of  direct  serous 
sewing,  and  if  for  any  reason  the 
mucous  coat  be  then  included,  a 
supplementary  superficial  stitch  of  the  serous  membrane  should  be  made 
to  complete  the  union.  The  serous  surfaces  should  be  brought  in  contact 
with  each  other  before 
transfixion  by  the  turn- 
ing in  of  the  borders,  as 
indicated  in  the  illustra- 
tion (Fig.  782). 

The  Continuous  Su- 
ture (Dupuytren)  (Fig. 
782).— The  name  of  the 
suture  defines  its  ar- 
rangement. This  form 
is  exceedingly  useful  in 
joining  the  borders  of 
long  cuts  of  either  a 
serous  or  cutaneous  sur- 
face. In  the  former 
the  stitches  are  placed 
closer  together  than  in 
the  sewing  of  cutane- 
ous  surfaces,  and  the  cut  surfaces  of  the  wound  are  brought  directly  in 

contact  with  each  other. 

The  Gehj  Suture  (Fig.  783). 
— In  Gely's  method  a  long  su- 
ture is  selected  and  armed  with 
a  needle  at  each  end.  The 
needles  are  inserted  near  one 
angle  of  the  wound,  about  two 
lines  from  the  edges,  and  car- 
ried along  the  tissues  of  the 
bowel  for  a  sixth  of  an  inch, 
then  brought  out  precisely  on 
Pig.  786. — The  Gushing  suture,  closing  wound.       tlie   same   level,   so  as  to  again 


Fig.  785. — The  Gushing  suture.  1.  Tlie  beginning.  2.  The 
knotting  3.  Suture  applied,  a,  h,  c,  in  3  and  3,  in- 
dicate needle  punctnres.  d,  e,  h,  i  indicate  track  of 
needle. 


DI'KUA'I'IONS   ON   VISCHIJA   (•(  ).\N  I'K  Ti:i )    WITH    I'MK'I'l'f  )\.i:r.M.     r,2i 

apiu'iir  uu  the  iK-ritoiiejil  siirfaci!  (d).  Tlie  sutures  are  llieii  crossed,  and  tlie 
needles  {)assed  as  before  (d).  Jf  a  knut  be  made  at  eaeh  (;rossiiig,  slipping 
of  tlie  sutures  will  l.c  prevented  (c).  'J'lie  nuniber  of  the  crossings  will 
vary  with  the  size  of  the  cut.  ]\y  this  nietliod  tlie  edges  of  the  wound  are 
thoroughly  inverted  (Fig.  T.S-l),  aiul  all  danger  of  extravasation  is  i)revented. 
This  suture  is  not  frecpuMitly  employed,  and  although  a  good  one  is  not  as 
readily  understood  nor  so  ])roniptly  a])plied  as  are  the  following.  It  is  some- 
times described  and  figured  as  including  the  mucous  membranes,  a  ste])  that 
ought  not  to  be  practiced. 

T/ie  Cnslting  Si(tiire. — In  this  suture  the  needle  does  not  enter  the  cav- 
ity of  the  gut,  but  instead  it  includes  the  serous,  muscular,  and  submucous 
fibrous  coats.  The  sewing  is  commenced  as  shown  in  Fig.  T.S.J.  The  thread 
is  knotted  and  the  stitclies  are  taken  in  the  manner  indicated,  and  when  the 
thread  is  drawn  tight  the  wound  is  closed  and  the  suture  is  buried  (Fig.  786). 
The  final  tying  is  illustrated  also  (Fig.  785). 


Fig.  787.— The  Lembert  suture,  a.  Se- 
rous coat.  J).  Muscular  coat.  c.  Sub- 
mucous fibrous  coat. 


Fig.  788. — The  Czerny-Lembert  suture. 
a.  Serous  coat.  b.  Muscular  coat, 
c.  Submucous  fibrous  coat. 


The  Lembert  Suture. — By  this  method  the  serous  borders  are  infolded 
(Fig.  787)  and  the  sutures  are  passed  through  them  at  about  a  tenth  of  an 
inch  from  the  edges  of  the  wound,  being  placed  about  the  same  distance 
apart.  The  number  of  stitches  and  the  amount  of  tissue  included  will  be 
governed  by  the  thickness  of  the  tissue  and  the  strain  exercised.  The 
rapidity  of  intestinal  sewing  can  be  increased  if  four  traction  sutures  be 
inserted,  two  on  either  side  of  the  divided  gut  in  the  line  of  the  tissues  to 
be  stitched.  These  pairs  of  sutures,  one  at  either  end,  are  made  tense  in 
opposite  directions,  thus  raising  parallel  folds  of  serous  membrane  through 
which  the  intestinal  sutures  are  passed  (Fig.  8G9). 

The  Czerny-Lembert  Suture  (Fig.  788). — Two  rows  of  sutures  are  em- 
ployed in  this  method,  neither  of  which,  however,  is  passed  through  the 
mucous  membrane.  The  first,  the  deep  series,  brings  the  edges  of  the  mu- 
cous membrane  together  ;  the  second,  the  Lembert,  are  passed  as  before 
indicated.  The  introduction  of  the  first  series  is  materially  aided  by  the 
eversion  of  the  mucous  membrane.  After  rectification  of  the  walls  in  end- 
to-end  sewing,  the  majority  of  the  knots  should  be  within  the  bowel;  iu 
the  closure  of  small  wounds  thev  are  without. 


622 


OPERATIVE   SURGERY. 


The  WoJfler  Suture. — Wolfler  joins  the  divided  ends  of  intestine  by  two 
rows  of  interrupted  sutures.  The  first,  the  outer,  row  includes  the  serous 
and  muscular  structures  (Fig.  789),  the  second,  the  inner,  includes  the 
mucous  and  submucous  tissues  (Fig.  T90).     The  sutures  are  tied  internally 


Fig.  789.     The  Wolfler  su- 
ture, sectional  view. 


Fig.  790.- 


-The  Wolfler  suture,  joining  the  raucous  and 
submucous  coats. 


throughout  except  the  last  few.  The  direction  of  the  manipulations  in 
these  latter  is  reversed  for  obvious  reasons. 

The  Jabouley-Briau  suture  differs  in  the  construction  from  the  preceding 
in  no  important  practical  respects. 

The  Giissenbauer  Sutiwe. — By  this  form  of  suture  the  submucous, 
fibrous,  and    serous  tunics  of  the  intestine   are    brought    in  place  at   once 


Fig.  791. — The  Gussenbauer 
suture. 


Fig.  792. — The  Halsted  suture,  closure  of  longi- 
tudinal incision. 


(Fig.  791).     However,  this  stitch  is  complicated  and  somewhat  tedious,  and 

affords  no  additional  security  to  repay  for  the  slowness  of  execution  and 

difficulty  attending  its  use. 

The  Halsted  Suture  {Mattress 
or  Quilt  Suture). — The  stitches 
of  this  suture  are  of  the  nature  of 
the  Lembert.  They  are  passed 
so  as  to  include  some  of  the  tough, 
submucous  fibrous  coat  (Fig.  792). 
Tying  should    be   omitted,  when 

practicable,  until  all  of  the  stitches  are  in  place. 

Tlie  Johert  Suture. — Jobert's  suture  is  employed  to  unite  the  divided 

extremities  of  a  bowel.     Identify  the  proximal  and  distal  ends  by  examina- 


FiG.  793. — The  Halsted  suture,  end-tu-end  sewing. 


urKKAIInNS   ON    ViSCKKA   (ONXKCTEl)   Willi    I'KIilTON JIL'M.     023 


tion  and  by  Nothniigcl's  test — chloride  of  sodium  causes  reverse  peristalsis — 
dissect  away  the  mesentery  for  a  third  of  an  inch  from  either  end  of  tiie  gut; 
transfix  the  proximal  end  with  one  needle  armed  with  a  long  suture  at  the 

site  of  mesenteric  attachment  (a)  and  with 
another  at  a  point  in  the  border  opposite  to 
it  (/v)  (Fig.  794);  invert  the  margin  of  the 
distal  end  (Fig.  T'Jo) ;  introduce  two  sutures 


Fig.  794. — The  Jobert  suture,  bring- 
ing ends  together. 


Fig.  795. — The  Jobert  suture,  longitudinal 
section,     a.  Peritoneal,     b.  Muscular,    c. 

Mucous  coats. 


at  either  side  of  the  gut  in  a  simihir  manner ;  arm  each  end  of  the  liga- 
tures with  a  needle,  and  transiix  from  within  outward  the  inverted  portion 
at  points  corresponding  to  the  sites  of  transfixion  of  the  proximal  end ; 
draw  the  upper  end  of  the  bowel  into  the  lower  and  tie  the  sutures  at  the 
outer  side  (Fig.  790).     When  necessary  a  greater  number  of  sutures  may  be 

applied  in  a  similar  manner  and  tied  (Fig.  797). 
This  course  adds  greater  security  to  the  union. 
The  application  of  continuous  sutures  to  the 
line  of  junction  should  be  avoided,  as  the  sew- 
ing will  interfere  with  the  nutrition  of  the  in- 
verted part  still  more  and  increase  the  danger  of 
sloughing  that  exists  already  in  a  certain  degree. 
An  occasional  interrupted  suture  (a)  may  be  in- 
serted to  strengthen  the  union. 
Se)i7i  modified  this  metliod 
in  a  very  important  manner. 
Into  the  upper  end  of  the 
bowel  he  introduced  a  common 
soft-rubber  band  of  the  length 
of  the  width  of  its  caliber  and 
joined  it  to  the  margin  of  the  bowel  with  a  continuous  fine  pj^^  797— The  Jo 
catgut  suture,  thus  preventing  the  protrusion  of  the  bert  suture,  fixa- 
mucous  membrane  and  causing  the  end  of  the  gut  to 
assume  a  tapering  appearance.  Two  fine  catgut  sutures 
are  then  passed  from  within  outward  at  opposite  sides  of 
the  bowel,  as  in  the  preceding  method,  transfixing  the  rubber  ring  and 
the   wall   of   the   intestine    (Fig.  798).      Both   ends   of   these   sutures  are 


Fig. 


ry6. — The  Jobert  method, 
sutures  tied. 


tion  sutures  tied. 
n.  interrupted  su- 
ture. 


024 


OPERATIVE  SURGERY. 


margin. 


Fig.  798. — Senn's  modification  of  Jobert's  suture. 
Rubl^er  ring  sewed  in  position. 


then  caused  to  pass  from  within  outward  through  the  serous  and  muscular 
coats  of  the  distal  end  of  the  bowel  about  a  third  of  an  inch  below  the 
The  upper  is  then    drawn   carefully  downward   into   the   lower 

extremity  by  aid  of  the  su- 
tures, while  the  margins  of 
this  latter  extremity  are  cau- 
tiously inverted  with  the  aid 
of  a  director  or  probe.  The 
sutures  are  tied  as  before,  no 
additional  ones  being  re- 
garded as  necessary.  The 
rubber  ring  serves  the  im- 
portant purpose  of  facilita- 
ting the  invagination,  of 
easing  the  suture  tension, 
and  obviating  capillary 
drainage  of  the  sutures 
themselves.  Sooner  or  later 
the  ring  comes  away  in  the  natural  form.  An  ordinary  rubber  band,  short- 
ened by  tying  the  ends  with  catgut,  will  suffice  for  the  purpose. 

Tlie  Remarks. — The  Lembert,  Gushing,  and  Halsted  sutures  can  be  ap- 
plied by  those  of  comparatively  limited  experience,  and  neither  of  them 
encourages  infection  by  capillarity.  The  remaining  varieties  are  more  com- 
plex and  difficult  of  application,  and  open  to  the  criticism  of  inviting  infec- 
tion of  the  tissues  because  of  their  association  with  the  mucous  lining  of  the 
intestine.  However,  inasmuch  as  time  is  an  important  desideratum  in  intes- 
tinal sewing,  the  operator  ought  always  to  employ  the  suture  with  which  he 
is  most  familiar,  provided  it  meets  the  demands  of  proper  repair. 

Intestinal  Approximation. — The  approximation  of  the  small  intestines 
with  each  other  and  with  the  remaining  hollow  viscera  of  the  digestive 
system  in  such  a  manner  as  to  cause  a  change  in  the  regular  channel  of 
transmission  of  the  contents,  is  a 
procedure  of  modern  practice. 
End-to-end  and  lateral  approxi- 
mation (intestinal  anastomosis) 
are  the  common  methods  of 
intestinal  operation.  End-to- 
end  approximation  is  done  by 
means  of  common  (Lembert  and 
Halsted)  and  special  suturing 
combined  with  invagination,  as 
has  been  described  already 
(Figs.  793  and  794).  In  addi- 
tion to  these  methods  others 
have  been  devised  which  are 
both  prompt  and  effective,  and 
the  result  of  ingenious  concep- 


FiG.  799. — Maunsell's  method,  passing  traction 
sutures. 


ol'llKA'I'InXS   ON    VISCKUA    CONNKC'I'KI)    Willi    I'KKITON^.UM.     f]2; 


tion  :iik1  putii'iit,  laborious   upplicaticjii.     It  is  possible  to  describe  in  this 
limited  space  only  those  now  in  common  use. 

Mdtnise/rs  Mclhod. — The  iii<,'eMious  mctliod  devised  by  Maunsell  is  cti- 
titlcil  to  much  consideration.  The  technifjue  of  the  method  is  substantially 
as  follows  :  After  carefully  freeing  the  lumen  of  the  bowel  of  its  contents 
for  some  distance  at  either  side  of  the  proposed  division,  and  cijinpressing  it 
to  prevent  return,  the  lield  of  o])eration  is  j>rotected  by  gauze  pads,  and  tiie 
resection  made.  The  parts  are  then  tiioroughly  cleansed,  the  wound  in  the 
mesentery  is  closed,  and  the  proximal  and  distal  ends  {a,  a')  of  the  intestine 
are  temporarily  united  with  each  otlier  by  two  sutures,  the  extremities  of 
which  are  left  long.  One  of  these  sutures  is  so  introduced  from  within 
(a)  outward  as  to  include  the 
wall  of  the  gut  and  the  mes- 
entery (b)  at  that  side  (Fig. 
79'J),  thence  carried  across  to 
the  opposite  extremity  (/>') 
and  inserted  upward  and  in- 
ward through  the  mesentery 
and  bowel  into  the  lumen,  go- 
ing across  it  downward  and 
outward,  piercing  the  tissues 
as  before,  finally  passing 
through  the  mesentery  and 
entering  the  bowel  at  a  point 
adjacent  to  that  of  primary 
departure,  leaving  the  free 
ends  of  the  suture  handily  placed  for  subsequent  grasping  (Fig.  ?99).  The 
second  suture  unites  the  borders  of  the  intestinal  ends  opposite  to  the  pre- 
ceding one  in  a  manner  easily  demonstrated  by  the  cut. 

Both  sutures  having  been  tied  after  a  careful  adjustment  of  the  borders 
of  the  bowel  (Fig.  800),  a  longitudinal  slit  an  inch  and  a  half  in  length  is 
made  through  the  free  border  of  the  larger  extremity,  about  two  inches  from 


Fig.  800. — Maunsell's  method,  ends  ail  justed. 
Longitudinal  slit  being  made  («). 


Fig.  801. — Maunsell's  method,  traction  sutures  (d.d)  carried   ihrough   longitudinal  slit. 
a.  b,  c.  ^Mucous,  muscular,  and  serous  coats.    /.  Mesentery. 

the  end,  by  means  of  a  scalpel  passed  upward  through  a  pinched-up  portion 
(Fig.  800,  a)  of  the  intestinal  wall  at  that  situation.     The  ends  of  the  trac- 


626 


OPERATIVE   SURGERY. 


tion  sutures  carried  into  the  intestinal  lumen  and  out  through  the  slit  by 
means  of  forceps  (Fig.  801),  are  now  jiulled  upon   {d,  d),  thus  causing  the 


irrn'iy 


Fig.  802. — MaiiiLseirs  method,  cum])arative  relations  of  intestinal  surfaces  shown. 

extremities  of  the  intestinal  segments  to  be  dragged  through  the  opening 
(Figs.  8U2  and  803)  and  to  appear  above  as  two  concentric  rings  of  in- 
testinal tissue.  While  held  in 
this  position  by  the  temporary 
sutures,  the  borders  of  the 
rings  are  transfixed  through 
both  walls  with  a  cambric  needle 
(a)  armed  with  horsehair  su- 
tures. At  each  transfixion  the 
suture  is  caught  at  the  middle 
with  forceps,  drawn  upward,  di- 
vided and  each  half  tied,  there- 
by forming  two  independent 
sutures.      About     eighteen     or 

Fig.  80:5. — Maunseirs  method,  intestinal  extremi-  twenty  of  these  sutures — the  re- 
ties  drawn  through  the  longitudinal  sht ;  sew-  g^^j^  ^^  ^^j^g  ^^  ^g^  transfixions 
nig  began. 

— are    thus  placed    (Fig.    804). 

Finally,  the  temporary  sutures  are  cut  short,  the  invaginated  ends  by  gentle 
traction  are  reduced,  the  longitudinal  slit  (b)  is  closed  with  Lembert  su- 
tures, and  the  operation  is  completed  (Fig.  805). 

Segments  of  intestine  of 
unequal  size  are  readily  unit- 
ed by  this  method  in  the  fol- 
lowing manner  (Fig.  800)  : 
Unite  the  mesenteric  borders 
with  a  temporary  suture  (a) 
as  in  the  preceding  instance ; 
transfix  the  sides  of  the  larger 
segment  by  a  simple  tempo- 
rary suture  (b)  passed  so  as  to 
include  the  superior  border 
of  the  smaller  segment,  and 
tie  it,  leaving  the  ends  long  as 


Fig.  804. — Maunsell's  method,  borders  sewed. 


OPERATIONS   ON    VISCERA   CONNK( 'IHD    WITH    l'ERITONM':UM.     (527 

before  ;  jjuss  a  third  sutiiio  (c)  tlirougli  the  walls  of  the  intestine  at  the  highest 
point  of  the  larger  segment ;  make  a  longitudinal  incision  (d)  at  the  superior 
border  of  the  larger  segintnit  two 
inches  frorii  the  end  ;  pass  the 
ends  of  the  sutures  through  it, 
draw  upon  them  so  as  to  cause 
the  ends  of  the  segments  to  ap- 
pear above  the  opening,  where 
they  are  sewed  in  the  manner  al- 
ready described,  and  illustrated 
(Figs.  802  and  803),  after  which 
the  longitudinal  slit  (b)  is  closed 
with  Lembert  sutures  (Fig.  807). 
If  the  difference  in  the  diame- 
ters of  the  segments  be  great,  it  is  better  that  a  V-shape<l  portion  be  removed 
from  the  superior  border  of  the  larger  one.  After  excision  of  a  portion  of  the 
duodenum  and  of  the  pyloric  end  of  the  stomach  (Fig.  808),  the  unequal 


Fii;.  N05.- 
pletcd. 
closed. 


Maunsi'irs 


a.  Line  of  intestinal  union. 
c.  Mesentery  sewed. 


r7 


^— ^-^-^--.'~ 


Pig.  806. — Maunsell's  method,  segments  of  unequal  size. 

extremities  can  be  united  with  each  other  by  first  placing  traction  sutures  in 
a  manner  similar  to  that  in  the  anastomosis  of  unequal  intestinal  segments. 
The  long  ends  of  the  traction  sutures  {a,  a,  a)  are  then  passed  into  the  stom- 


FiG.  807.— Maun>cirs  nKlhod.  uneiiual  ^Lgmcnts.  continuity  restored. 

ach  and  out  through  a  slit  made  at  its  anterior  surface  (b),  through  which  the 
divided  borders  are  drawn  by  the  sutures,  and  sewed,  as  for  intestinal  union. 
A  movable  part  of  the  duodenum  or  the  jejunum  can  be  anastomosed  with  the 
46 


C28 


OPERATIVE   SURGERY. 


stomach  by  this  method.  A  portion  of  the  greater  curvature  of  the  stomach, 
along  with  the  intestine  in  question,  is  exposed  at  the  abdominal  wound 
(Fig.  809),  and  the  under  surfaces  are  joined  with  two  or  three  Lembert 
sutures.  Corresponding  openings  are  then  made  in  the  apposed  surfaces  of 
the  viscera,  and  a  traction  suture  is  passed  through  the  opening  of  each  at  the 
adjacent  angles  of  the  wounds  (b),  and  the  ends  are  introduced  into  the 

stomach  and  passed  out  through  a 
long  longitudinal  slit  («)  located  at 
some  distance  above  the  point  of 
junction,  by  means  of  wliich  the  di- 
vided borders  are  drawn  upward  and 
out  of  the  superior  incision  and 
sewed,  as  in  the  foregoing  instances. 
If  the  superior  borders  of  the  open- 
ings in  the  respective  viscera  be 
united  with  a  few  Lembert  sutures, 
the  upward  displacement  through 
the  opening  will  be  more  readily  and 
safely  accomplished  and  the  final 
sewing  greatly  facilitated.  The  pre- 
ceding illustrations  of  the  application  of  this  method  are  an  earnest  of  its 
utility  in  other  portions  of  the  intestinal  tract  to  which  its  technique  can 
be  applied. 

The  Comme7ii-<. — The  method  of  Maunsell  is  easily  and  rapidly  em- 
ployed, and  is  readily  available,  since  its  application  needs  the  support  of  no 
special  agents.  However,  it  is  open  to  the  objections,  first,  of  the  possibility 
of  inviting  drainage  infection  of  the  peritongeum  because  of  the  through-and- 
through  placing  of  the  sutures,  and,  second,  of  liability  to  subsequent  cica- 
tricial contraction  at  the  line  of  sewing  caused  by  the  ulceration  processes 
incident  to  healing.  The  former  objection  can  be  met  by  a  supplementary 
sewing  of  the  serous  surfaces   along  the  line  of    their   junction  after  the 


Fig.  808. — Pylorectomy,  Maiinsell's  method. 


Fig.  8(1!).— (ia-tiii-iuterostomy,  Maunsell's  method. 

reduction  of  the  invaginated  borders.  It  is  claimed  (Wiggin)  that  the 
second  objection  has  no  practical  foundation.  It  is  better  to  ligature  the 
mesenteric  vessels  that  fall  in  the  line  of  incision  before  their  division  than 


Ol'KKATlOXS   OX    VlSCKliA    CONiNKCTKI)    Willi    I'liKl'lUN .KUM.     (529 


after,  for  obvious  rousous.     Tlio  extroinitics  of  tho  divided  intestines  should 
bo  well  supplied  with  blood  to  prevent  their  becoming  gangrenous, 

Murphy''s  Button. —  Dr.  .1.  B.  Murphy  has  devised  this  singularly  clever 
mechanism  for  the  purpose  of  end-to-eud  and 
lateral  api)roximatiou  of  hollow  viscera  (Fig.  81<»). 
The  button  is  formed  of  two  cujis,  one  of  which 
is  known  as  the  spring  cup  {a).  Each  is  so  con- 
structed as  to  lit  its  fellow  in  a  manner  that  se- 
cures perfect  and  continuous  apposition  of  the 
serous  surfaces  of  the  open  ends  of  the  bowel, 
while  at  the  same  time  the  spring  (c)  exercises  a 
gentle  pressure  on  the  intervening  tissue,  wliich 
is  sooner  or  later  severed  by  it,  thus  liberating  the 
button  in  the  intestinal  canal.  In  addition  to 
the  button,  intestinal  clamps  (Fig.  808)  or  other 
means  of  controlling  the  lumen  of  the  intestine  should  be  at  hand ;  also  a 
needle  and  silk  sutures,  and  forceps  for  grasping  the  stem  of  the  button. 

After  the  necessary  cleansing  and  fortification  of  the 
contiguous  parts  against  infection,  and  the  control 
of  the  lumen  of  the  gut  is  effected,  a  "puckering 
string  "  is  placed  around  the  free  border  of  the  end 
of  the  bowel  (Fig.  811,  e),  commencing  opposite 
to,  and  continuing  on  one  side  down  to,  the  mesen- 


i-'Ki.  810.— TIk;  .Murphy  l.iit- 
toii.  <i.  Sf>riiifif  cuf).  b. 
Kocciviiif,'  Clip.  r.  Wire 
spriiif^  regiilatinf:^  flarifje  p. 
.s.  .Stem  witli  projcotii)f^ 
si)riiigs. 


Fig.  812. — Cup  seized  for  introduction. 
Fig.  813. — Spring  cup  seized  for  introduction, 
flange  should  be  pushed  down  before  grasping. 


Spring 


Fio.  81 1.— Section  of  small 
intestine  and  nicsonterv. 
a.  Serous  coat.  h.  Mus- 
cular coat,  c.  Submucous 
fibrous  coat.  d.  Artery 
to  bowel.  e.  Reverse 
overstitch  and  puckering 
string.  f.  Triangular 
space,    g.  ^Mesentery. 


tery,  which  is  grasped  by  a  reverse  overstitch  (e), 
followed  by  a  continuation  of  the  topstitch  up 
the  opposite  side  to  the  point  of  beginning.  It 
is  noted  that  the  ends  of  the  suture  are  left  long 
that  they  may  be  readily  grasped.  One  cup  of  the 
button  is  then  seized  at  the  stem  with  forceps 
(Fig.  812),  and  is  carried  into  the  open  end  of  the 
intestine  and  held  there,  while  the  puckering  string 
is  drawn  tightly  and  tied  at  the  base  of  the  stem. 


630 


OPERATIVE  SURGERY. 


Fig.  814. — Parts  prepared  for  joiniii 


The  remaining  cup  and  end  of  the  bowel  are  treated  in  a  siniihir  manner 
(Fig.  813),  after  which  the  cups  are  joined  and  pushed  firmly  together 
(Fig.  814).  Extremities  of  unequal  diameter  can  be  united  in  a  similar 
manner  to  that  employed  for  those  of  a  like  caliber. 

For  the  purpose  of  making  a  longer  and  perhaps  more  permanent  open- 
ing between  approximated 
viscera,  Murphy  devised 
an  oblong  button  which 
does  not  differ  in  its  mech- 
anism and  application  from 
the  round  button  in  any 
essential  respect  (Fig.  815). 
This  variety  is  commended 
by  Murphy  for  use  in  lateral  approximation  of  intestines  with  each  other 
and  in  the  performance  of  gastro-enterostomy. 

Lateral  Approxitnation. — Either  the  round  or  oblong  button  can  be 
employed  in  lateral  approximation.  The  use  of  the  latter  is  followed  by 
much  the  larger  anastomotic  opening,  and  for  this  reason,  at  least,  may  be 
.regarded  the  better  agent  for  the  purpose.  The  puckering  string  in  lat- 
eral approximation  is  placed  in  each  instance  opposite  to  the  mesenteric 
attachment,  as  indicated  in  Fig.  816.  A  longitudinal  slit  is  then  made  in 
the  bowel  of  sufficient  length  to  permit  the  entry  of  the  form  of  button  em- 
ployed. As  before,  the  parts  of  the  button  are  grasped  separately  with  for- 
ceps, introduced  into  the  respective  openings,  raised  outward,  the  strings 
drawn  firmly  and  tied  at  the  base  of  the  stems.  After  which  the  parts  of 
the  button  are  united  and  firmly  pressed  together. 


Fig.  815. — Murphy's  oblong  button  and  key. 


The  Precautions. — The  ends  of  the  puckering  strings  should  be  cut  short, 
so  that  they  will  not  be  grasped  by  the  closure  of  the  button,  and  thus  delay 
its  escape.  The  button  should  fit  the  intestine  loosely,  otherwise  the  pressure 
of  the  rim  will  cause  sloughing  and  perforation.  The  intestinal  contents 
should  be  kept  in  a  fluid  state,  to  prevent  the  plugging  of  the  openings  in 
the  button.     If  the  gravity  of  the  agent  be  sufficient  to  cause  kinking  of 


Ul'HIiATlUNS   ON    VISCKIJA    ('ONNKCTKD    WITH    I'KUiToN.Kr.M.     «;;jl 

the   intestiiio  imd  a  projuT  acljuslriicnt   of   the   rt-hilioiis  be   iiiipriu-ticuble, 
another  lueiius  of  uuiou  shouhl  be  substituted. 


Fui.  SI 6. 


-LalL'ral  upiiroximation  with  >[urphy's  button. 
and  ;m  opening  made. 


Purse-string  sutures  placed 


The  Conn>iefif.'<.—'n\e  use  of  the  Murpliy  button  is  open  to  the  rational 
objection  that  it  introduces  into  the  intestine  u  foreign  body  of  considerable 
size,  the  effect  and  final  escape  of  which  are  somewhat  problematical.  How- 
ever, the  rapidity  and  ease  with  which  it  can  be  employed,  as  compared  with 
the  longer  time,  greater  difficulty,  and  absence  of  general  knowledge  and 
experience  in  the  more  complicated  methods  of  practice,  together  with  the 
success  attending  its  use,  have  established  for  it  a  definite  and  commendable 
station  in  intestinal  surgery.  The  oblong  button  is  employed  less  frequently 
in  lateral  anastomosis  than  are  other  methods  of  approximation.  In  the 
three  instances  in  which  this  form  was  used  by  the  writer,  the  outcome  was 
satisfactory  in  all  respects. 

The  Laplace  Intestinal  Ap- 
proximation Foi'ceps. — The  in- 
strument consists  of  two  sym- 
metrically shaped  compression 
forceps,  with  semi  -  elliptical 
blades,  placed  in  juxtaposition 
with  the  concavities  of  the 
blades  turned  toward  each 
other  and  locked  together  with 
a  clamp  (Fig.  817).  The  clamp 
grasps  the  two  forceps  at  their 
joints,  and  is  secured  on  either 
side  by  a  pivot  placed  on  a  line 
with  the  axis  of  the  joints,  so 
that,  all  movements  taking 
place  around  a  common  axis, 
both  forceps  can  be  opened  and 
shut  simultaneously  to  an  equal 
extent.  When  both  forceps 
are   locked  and   their  handles 


l-'u;.  SIT. — Thf    I>aplace 
forceps  unlocked. 


Fig.  Sis. — The  Laplace 
forceps  locked. 


632 


OPERATIVE   SURGERY. 


parallel,  the  closed,  semiellii)tical  blades  of  each  side  are  brought  opposite 
to  each  other  so  as  to  form  one  complete  ellipse  (Fig.  818).  If  now  both 
forceps  be  opened  simultaneously  to  an  equal  extent,  the  primary  ellipse  is 
divided  into  two  by  the  separation  of  the  blades. 

The  7)1(1  fiipukd ion  of  the  instrvment  consists,  first,  in  ojieuing  it  so  as  to 
cause  an  even  separation  of  the  rings  and  in  inserting  one  of  the  rings  within 
each  lumen  of  the  segments  to  be  joined,  thereby  bringing  the  blades  in 
direct  contact  with  mucous  surfaces  internally,  while  the  serous  coverings 
remain  external  and  overlie  the  compressing  surfaces  of  the  rings.  The 
latter  are  then  compressed  together,  whereby  the  included  serous  surfaces 
are  brought  in  contact  and  the  coats  held  firmly  in  apposition  while  the 
sutures  are  inserted.  Serous  surfaces  are  brought  into  contact  throughout 
the  entire  circle  of  compression,  with  the  exception  of  the  site  of  exit  of  the 
handles  of  the  instrument  from  the  seat  of  operation  where  mucous  mem- 
brane lines  the  opening.  This  latter  is  of  advantage  rather  than  otherwise, 
for  on  withdrawal  of  the  instrument — which  is  done  by  unclasping  the  locks 
and  removing  each  lateral  half  separately — the  blades  of  each  half  in  their 
exit  sweep  over  mucous  membrane  only  and  come  in  contact  Avith  no  serous 
surface.  There  are  five  different  sizes  of  instrument  to  suit  the  various 
operations  of  anastomosis,  including  one  for  cholecystenterostomy,  and  an- 
other very  small  instrument  used  for  the  anastomosis  of  the  ureter  with  the 
intestine,  which  is  done  by  the  lateral  method. 

End-to-End  Aiyproximation. — In  end-to-end  approximation  the  ends  of 
the  intestine  are  first  tacked  together  with  four  equidistant  traction  sutures 
passing  through  all  the  coats.     One,  placed  at  the  site  of  junction  of  the 


Fig.  819. — End-to-end  approximation,  traction  sutures  in  place. 


mesenteric  borders,  is  inserted  with  special  care  to  include  both  layers  of 
each  mesentery,  so  as  to  close  the  triangular  space  of  each  segment  which 
exists  between  the  layers  of  the  peritonaeum  at  this  situation  ;  another  is 
inserted  at  a  point  of  the  intestine  opposite  to  this  one ;  of  the  remaining 
two  one  is  inserted  at  either  side,  midway  between  the  first  and  second 
sutures  (Fig.  819).  The  approximation  forceps  is  now  introduced,  with 
blades  closed,  into  one  of  the  spaces  between  the  sutures,  excepting,  how- 


UPKIvAl'lnNS   ON    VISCKUA    C'ONNKCTKI)    WITH    I'Kmi'oN.KlM.     (;;>3 


Fig.  820. — Eiid-to-oiid  iipiJi-oxiinalion,  forceps  in  place. 


ever,  those  sjmoca  next  to  the  suture  joininj^  the  mesenteric  borders.     'J'lio 
bhiiles  ure  then  0})ened,  iind  the  rings,  us  tliey  sepuriite,  are  nuido  to  j)u.ss 

one  into  eitlier  inlfstinal 

extremity.  If  the  edges 
of  the  gut  tend  to  evert 
instead  of  falling  l)ot\veen 
the  rings,  they  ran  readi- 
ly be  drawn  into  place  by 
a  single  turn  of  a  thread 
passed  around  the  line  of 
the  sutures  between  the 
blades.  The  instrument 
is  then  clamj)ed,  and  in 
so  doing  the  entire  se- 
rous surfaces  around  the 
openings  are  accurately 
brought  together  for  sew- 
ing, excepting  at  those 
extremities  of  the  slits  in  which  the  blades  rest  (Figs.  820  and  821).  The 
thread  is  withdrawn  just  before  the  blades  are  clamped.  The  further 
techni(|ue  is  the  same  as  in  end-to-end  approximative  anastomosis. 

The  Co7)imenis. — If  before  clamping  it  be  found  that  the  slits  have  been 
made  a  little  too  long  to  be  included  within  the  grasp  of  the  blades,  they  can 
be  shortened  by  a  little  lateral  traction  on  the  openings,  making  them  a 
diamond  shape,  and  thus  approximating  their  extremities.  The  external 
portion  of  the  adjusted  instrument  now  acts  as  a  handle  to  hold  the  seat  of 
operation  in  proper  position,  which  is  of  particular  value  in  such  operations 
as  cholecystenterostomy  and  von 
Hacker's  operation  for  gastro- 
enterostomy, where  the  surfaces 
to  be  sewed  are  difficult  of  ap- 
proximation. 

When  the  sutures  have  been 
placed  for  one  half  tlie  circumfer- 
ence of  the  rings,  by  a  half  turn 
of  the  instrument — and,  if  a  con- 
tinuous suture  be  used,  at  the 
same  time  passing  the  needle  be- 
hind the  seat  of  operation — the 
remaining  half  of  the  circle  is 
brought  conveniently  into  place 
for  the  completion  of  the  sewing. 
In  the  withdrawal  of  the 
blades  from  within  the  intestine, 
each  forceps,  after  unlocking, 
must  be  first  pulled  directly  outward  until  the  elbow  at  the  junction  of  the 
straight  with  the  curved  portions  of  the  blades  is  well  clear  of  the  intestine 


Fig.  831. — End-to-end  approximation,  sutures 
placed. 


634 


OPERATIVE   SURGERY. 


before  the  handles  are  swung  around  to  finally  extricate  the  semi-ellipse.  The 
operation  is  completed  by  the  inversion  of  the  pouting  mucous  membrane 
at  the  opening  which  remains,  and  the  closure  of  the  latter  with  sutures. 

Lateral  Approximation. — In  lateral  approximation  slits  are  made  in  the 
two  hollow  viscera  to  be  joined,  each  a  little  longer  than  the  transverse  diam- 
eter of  the  elliptical  rings  of  the  instrument,  so  as  to  just  admit  of  the  easy 
entrance  of  the  rings  through  the  openings.  The  anastomosis  forceps  is 
opened  and  one  metal  ellipse  is  inserted  into  one  of  the  slits  and  the  other 
ellipse  into  the  other  slit,  both  passing  entirely  within  the  interiors  of  the 
respective  viscera.  Slight  traction  is  then  made  on  the  handles  of  the  in- 
strument to  draw  the  straight  portions  of  the  blades,  which  are  just  above 
the  rings,  snugly  into  corresponding  extremities  of  the  slits,  which  traction 
makes  the  latter  assume  a  position  in  line  with  the  short  diameters  of  the 
ellipses  and  become  parallel. 

The  Invagination  Forceps. — This  instrument  is  a  long  and  narrow 
straight  forceps,  devised  by  Laplace  (Fig.  822),  by  means  of  which  the  free 
end  of  a  divided  intestine  is  grasped  close  to  its  pe- 
ripheral margin  and  the  included  tissues  invaginated 
deeply  within  the  gut,  after  which  the  serous  borders 
are  sewed  over  the  invaginated  portion.  The  instru- 
ment is  left  in  situ  as  long  as  possible  during  the  sew- 
ing, and  when  finally  withdrawn  the  site  of  its  exit  is 
likewise  closed  by  suturing. 

Dr.  Laplace  states  the  advantages  of  the  anasto- 
mosis forceps  as  follows : 

"  First,  rapidity  and  accuracy  of  suturing  without 
leaving  any  foreign  substance  within  the  gut ;  second, 
an  absolute  control  of  the  field  of  operation  by  means 
of  the  assistance  of  the  handles  of  the  forceps;  third, 
the  facility  with  which  the  forceps  is  applied,  pre- 
venting the  escape  of  intestinal  contents  during  the 
operation." 

The  Comments. — In  two  anastomoses  performed  on 
dogs  by  Dr.  Laplace  there  occurred  a  subsequent  clo- 
sure of  the  opening  of  communication  between  the 
viscera  joined.  It  happened  where  a  thin  intestinal 
coil  was  joined  to  a  thicker  one,  and  the  failure  to 
establish  a  permanent  communication  was  ascribed  to  the  fact  that  the 
sutures  were  not  made  to  pass  deeply  enough  through  the  coats  of  the 
thicker  segment  to  shut  off  the  circulation  from  the  tissues  immediately 
around  the  opening  in  the  same,  so  that,  instead  of  a  sloughing  of  the 
margin  of  the  aperture,  granulations  sprang  up  from  the  raw  edges  and 
effected  the  closure  of  the  opening. 

While  this  apparatus  is  ingenious  and  permits  of  rapid  execution,  it  is 
apparently  open  to  the  objection  so  common  in  other  methods — subsequent 
closure  of  the  intestine  from  unwelcome  repair.  The  status  of  its  useful- 
ness in  the  human  economy  is  not  yet  established. 


Fig.  822.— The  Laplace 
invagination  forceps. 


OPERATIONS   ON    VISCKRA   CONNKCTP]!)    Willi    I'KKiroN.KU.M.     0.15 

Boiie  Bobbins.  Hune  bobbins  us  a^'ents  of  intcslinal  ajjproxiinution  are 
associati'd  in  i(k'a  with  the  devices  of  Senn  and  Murphy.  Tliey  are  regarded 
by  many  as  siiiipliT,  safer,  (piite  as  promptly  applied  as  the  former,  and  less 
likely  to  be  followed  by  stricliire.      iMttderer  commends  potato  boijbins. 

The  Decalcijied  Hone  llohbin  of  liobson  (Fig.  8"^3). — The  manner  of  its 
application  is  easily  comprehended  and  can  be  readily  practiced.    'J' wo  rows  of 


F'lO.  823. — The  bone  bobbin  of  Robson.     a.  Tlie  continuous  niuco-iniicoiis  .suture,     h.  Tlie 
continuous  scro-serous  suture. 

continuous  sutures — an  internal  mtico-mucous  (a)  and  an  external  sero- 
serous  {b) — are  employed.  Begin  by  introducing  the  external  sutures  at  the 
farther  half  of  the  intestine,  followed  at  once  by  the  internal  for  the  same 
distance.  Put  the  bobbin  in  place  and  complete  the  internal  muco-mucous 
suture,  followed  by  completion  of  the  external  sero-serous  suture.  The  con- 
tinuous is  employed  for  the  internal  suture.  Either  the  Lembert  or  the 
Gushing  variety  may  be  applied  externally.  When  great  haste  is  essential  a 
single  row  introduced  deep  enough  to  pierce  the  submucous  fibrous  coat 
will  suffice. 

I'he  Bone  Bobbin  of  Allmgham  (Fig.  824). — The  center  of  this  bobbin, 
and  for  a  quarter  of  an  inch  at  either  side  of  it,  is  decalcified,  and  there- 
fore is  not  influenced  by  suture  pressure.  The  remaining  portions  are  not 
decalcified.  The  shape  of  this  bobbin  tends  to  approximate  the  divided 
borders  when  closed  around  it,  also  opposes  their  slipping  away.  To  apply 
it,  carry  a  purse-string  suture  around  each  end  of  the  intestine  (^,  b) ;  insert 
one  end  of  the  bobbin  into  the  extremity  of  a  segment  of  intestine ;  draw 
the  suture  tightly  around  the  bobbin,  tying  with  a  single  knot  at  first ;  intro- 
duce the  remaining  end  of  the  bobbin  into  the  extremity  of  the  remaining 


Fig.  824. — The  bone  bobbin  of  Allinghani.     u.  Bone  bobbin  disconnected  and  in  place. 

segment  and  tie  as  before ;  push  the  ends  firmly  together  at  the  center  of 
the  bobbin  and  tie  an  additional  knot  in  each  ;  supplement  the  line  of  union 
with  continuous  or  interrupted  sutures  if  needed  {c).     This  method  of  prac- 


636 


OPERATIVE  SURGERY. 


tice  seems  insecure  without  the  supplementary  stitches.     Little  can  be  said 
as  yet  of  the  outcome  of  its  practical  application. 

The  Bone  Bobbin  of  Hayes  (Fig.  825). — The  ingenuity  of  this  bobbin 
entitles  it  at  once  to  respectful  consideration.     The  central  part  is  not  decal- 


Fig.  825. — The  bone  bobbin  of  Hayes,     a,  b.  Grooves  in  bone  bobbin,     e,  c,  h.  Sutures. 
c.  Distal  groove,     d.  Proximal  groove. 


cified,  and  for  the  reasons  relating  to  the  preceding  one.  It  has  two  grooves, 
proximal  and  distal  [a,  b),  and  is  partly  segmented.  Three  purse-string 
sutures  are  applied,  two  of  which  are  placed  similarly  to  those  of  the 
preceding  method  (c,  e),  the  third  being  subserous  (b),  and  well  indicated 
in  the  illustration.  The  ends  of  the  intestine  ai*e  lodged  securely  in  the 
proximal  groove  (c)  by  tightly  tying  the  marginal  sutures.  The  serous 
coat  of  the  proximal  segment  of  intestine  is  then  drawn  over  the  extrem- 
ity of  the  distal  and  securely  lodged  in  the  distal  groove  (b)  by  means  of 
the  subserous  suture  {b),  thus  invaginating  the  end  of  the  distal  segment. 
Lateral  approximation  can  be  carried  into  effect  by  means  of  the  but- 
ton with  but  a  single 
groove,  in  the  manner 
well  shown  in  the  illus- 
tration (Fig.  826).  Neu- 
ber's  decalcified  bone  but- 
ton (Fig.  827)  is  highly 
commendable. 


Fig.  826. — The  bone  bobbin  of  Hayes,  lateral  approxima- 
tion, e,  /.  Apertures  for  bobbin,  d,  c.  Marginal 
sutures,     k,  i.  Subserous  sutures. 


Fig. 


827. — Neuber's  tube  of 
decalcified  bone. 


The  India-rubber  Tube  Method  of  Robinson. — This  method  may  be  avail- 
able when  for  good  reasons  other  methods  of  practice  can  not  be  utilized 
(Fig.  828).  Stitch,  within  the  proximal  segment,  to  the  cut  border  a  piece 
of  rubber  tube  of  suitable  size,  three  or  four  inches  in  length,  and  scarify  the 
serous  surface  for  an  inch  from  the  extremity ;  dissect  off  the  mucous  mem- 


OPERATIONS   OX    VISCKRA   CONNECTKD    Wllii    l'KRITONiI<:UM.     G37 

braiie  from    the  distill   segment  fur  an    inch  with  seibsors,  and   curette  tlie 
freslieued  surface  to  destroy  the  intestinal  glands;  i)ush  the  i)ro.\imal  seg- 


„i::i)}.'li>riiii  !})•!>  !i,i,l!i.'r//,y   -Jmi, 


Fio.  828. — Till'   liidiiiriibbcr  tube  method  of  Robiiisijii,  loiif,'itudiiiiil  section. 


ment  into  tlie  distal  and  suture  the  serous  margin  of  the  distal  to  the  cor- 
responding serous  surface  of  the  proximal  part,  the  stitches  piercing  the 
serous  coat. 

The  Remarks. — The  stitches  connecting  the  tube  witli  the  gut  should  be 
tightly  drawn  to  facilitate  its  separation.  The  decalcified  bone  cylinders  of 
Jessert  and  Paul  may  be  used  instead.  In  these  methods  the  calibers  of  the 
intestinal  segments  should  correspond  in  size. 

End-to-end  apjjroximation  of  imequal  segments  of  intestine  can  be  easily 
accomplished  by  Maunsell's  method  (see  page  G27),  by  the  Murphy  button 
without  any  reduction  in  the  diameter  of  the  larger  segment,  and  by  the 
removal  of  a  longitudinally  placed  V-shaped  portion  from  the  larger  end.  In 
addition  to  these  methods,  Wehr  advises  that  the  end  of  the  narrower  bowel 
be  divided  obliquely  at  the  expense  of  the  convex  border  in  such  a  manner 
as  to  cause  the  open  extremity  to  conform  in  size  with  that  of  the  larger 
intestinal  segment  (elbowing)  (Fig.  8G7).  In  this  instance  two  rows  of 
sutures  are  employed,  the  same  as  in  end-to-end  sewing  in  other  methods. 

Lateral  Anastomosis. — Lateral  anastomosis  is  employed  to  establish  a 
continuous  coninuinication  between  the  intestine  above  and  the  intestine 
below  a  more  or  less  joerma- 
nent  obstruction  (Fig.  829). 
It  is  practiced  instead  of  re- 
section when  the  difficulty 
can  not  for  a  good  reason  be 
merely  removed. 

The  Method  of  Lateral 
Anastomosis  of  Senn. — Senn's 
practice  and  advocacy  of  lat- 
eral intestinal  anastomosis 
through  the  agency  of  decal- 
cified bone  plates  brought 
both  the  method  and  utility 
of  the  operation  into  promi- 
nence. The  plates  are  of 
three  sizes,  selected  according  to  the  age  of  the  patient  and  the  caliber  of 
the  viscus  under  consideration  (Fig.  830).  They  are  made  of  decalcified 
bone,  are  of  oval  shape,  and  provided  with  a  central  opening  to  correspond 


a 

Fig.  829. — Senn's  method  of  performing  lateral 
anastomosis,  a.  Plates  in  position  within  the 
intestine,     b.  After  completion  of  the  operation. 


638 


OPERATIVE   SURGERY. 


Fig.  830.— The  decalcified 
bone  plate  of  Seiin.  a,  a. 
Fixation  sutures.      J,  b. 


with  the  proposed  intercommunication  between  the  united  intestines.  The 
bone  plates  are  formed  from  sections  of  bone  sawed  from  the  femur  or 
tibia  of  the  ox,  and  decalcified  by  immersion  in  a 
ten-per-cent  solution  of  hydrochloric  acid,  which  is 
changed  every  twenty-four  hours  until  they  can  be 
bent  in  any  direction  without  fracture.  They  are 
then  washed  and  placed  for  a  short  time  in  a  weak 
caustic  solution  to  remove  the  acid.  Bone  bobbins 
are  prepared  in  a  similar  manner,  but  from  sections 
of  smaller  bones.  The  bone  plates  are  then  fash- 
ioned so  as  to  be  a  quarter  of  an  inch  in  thickness, 
two  and  a  half  to  three  inches  in  length,  and  an 
inch  in  width,  with  a  proper-sized  opening  made  by 
cutting  with  a  knife.  The  margins  of  the  opening 
are  provided  with  four  silk  sutures  in  the  follow- 
ing manner :  Thread  each  of  two  fine  sewing  nee- 
dles with  a  fine  aseptic  silk  thread  twenty-four  inches 
in  length ;  tie  the  ends  of  the  threads  together  and 
bring  the  needles  to  the  middle  (Fig.  831) ;  draw 
a  loop  (Fig.  832)  of  the  thread  through  each  of  the 
Approximation  sutures,  perforations  and  confine  the  loops  in  place  by  means 
c.cf.c.  Openings  in  plate  ^^  ^  thread  passed  through  them  and  firmly  tied 
and  anchor  thread.  ^  •        ^- n    -,      ^  ^ 

(Fig.  833).     Sta?n7n  simplified  the  arrangement  of 

the  sutures,  introducing  them  into  the  plates  in 
such  a  manner  as  to  correspond  with  each  other 
when  tied,  thus  properly  fixing  them  in  position 
(Fig.  834).  The  plates  are  properly  kept  for 
use  between  two  pieces  of  glass  immersed  in  a 
solution  made  of  equal  parts  of  alcohol,  glycerin, 
and  water. 

The  plates  are  applied  in  the  following  man- 
ner :  The  loops  of  intestine  to  be  joined  are 
drawn  out  through  the  abdominal  wound  and 
carefully  isolated  with  gauze,  the  contents  of  the 
bowel  pushed  aside  and  return  is  prevented  by 
some  form  of  intestinal  clamp.  An  opening  is 
then  made  in  the  long  axis  of  one  of  the  por- 
tions of  bowel  opposite  the  mesenteric  border 
nearly  equal  in  length  to  the  long  diameter  of 
the  perforation  in  the  plate  (Fig.  816).  The 
plate  is  inserted  into  the  bowel  endwise,  and  the 
borders  of  the  wound  are  properly  adjusted  to  its 
surface  by  traction  on  the  sutures,  aided  by  ma- 
nipulation with  the  fingers,  after  which  the  fixa- 
tion sutures  {aa')  are  carried  through  the  bor- 
ders of  the  wound  halfway  between  the  angles 
by  means  of  the  needles.     The  remaining  loop 


Fig.  831.— Silk  threads  tied, 
needles  at  the  middle. 


Ul'Hl{A'ri()NS   ON    VlSl'KltA   CONNECTHI)    WITH    I'KllITONJiUM.     039 


of  intestine  is  treutod  in  a  siniiliir  inainuT.  Severiil  sero-imisculiir  sutures 
are  tlu'U  inserted  beiiind  tiuf  phitt-s  (r)  and  the  internal  {<(')  lixation  sutures 
are  tied  (I-'lu;.  s:5"»).     The  intestinal   wounds  are  now  brought  into  apijosi- 

tion  and  confined  there  by  tying  and 
cutting  siiort  the  external  fixation  su- 
tures {(Id),  then  the  apposition  sutures 
{l/b,  b'b')  at  either  end.  The  operation 
is  completed  by  carrying  a  continuous 
suture  through  the  serous  surfaces  at  the 


Fig.  832. — Threading  Sean's  plate. 
Passing  first  loop. 


Fig.  833.— Threading  Senn's  plate.  Passing 
last  loop,  anchor  thread  (c)  passing  through 
three  loops. 


Fig.  834. — Staniin's  arrangement  of  sutures. 
a,  a.  a,  a.  Fixation  sutures,     b,  b,  b,b.  Approximation  sutures. 

anterior  borders  of  the  approximation  plates,  thus  fortifying  the  union  and 
increasing  the  area  of  contact  (Figs.  836,  837,  and  838). 


640 


OPERATIVE   SURGERY. 


The  Precautions. — Equal  contact  of  the  lips  of  the  wound  with  the 
plates  and  exact  apposition  of  the  free  borders  should  be  carefully  secured. 
Undue  force  in  tying  the  plate  sutures  should  be  avoided,  otherwise  the 
resulting  pressure  may  cause  sloughing  of  the  included  tissues. 


Pig.  835. — Lateral  anastoinosis,  Senn's  method.     Plates  iiitroduced. 


The  Remarks. — Scarification  of  the  serous  surfaces  included  in  the  lips 
of  the  wound  is  sometimes  practiced  with  the  idea  of  hastening  their  union. 
However,  there  is  but  little  reason  to  regard  this  step  as  essential.  Supple- 
menting the  line  of  junction  with  omental  grafts  (Fig.  888)  is  advised  by 
Senn  in  this  as  in  other  methods  of  procedure,  especially  if  insecurity  of 
union  be  suspected.  The  decalcified  plates  of  Senn  can  be  procured  of  those 
who  deal  in  surgical  supplies,  and  be  kept  at  hand  to  meet  the  emergency 
calling  for  their  use.     Other  plates  of  diverse  nature  are  employed  as  sub- 


FiG.  836.— Lateral  anastoinosis,  Senn's  method.      Plates  approximated,   sutures  tied, 
continuous  suture  introduced. 

stitutes.  The  catgut  rings  of  Abbe,  and  similar  rings  and  mats  of  Matas  and 
Brokaw  and  others,  while  useful  in  an  emergency,  are  less  reliable  than  the 
plates  of  Senn.  Cartilage  plates  made  from  the  scapula?  of  calves  were  em- 
ployed by  Stamm  with  good  results.     The  turnip  plates  of  Baracz  and  the 


()l'i:i;A'ri()NS   ON    VISCMRA    CONNKCTI';i)    Wnil    I'llKrroXyKL'.M.     Gil 

potato  [)hit(.',s  of  Diiwbiini  niv.  iin  I'unu'st  (jf  iii;,'('iii()iis  foiollioiiglit,  for  tliey 
can  bo  pr()rii})tly  made,  readily  applied,  ami  may  therefore  meet  an  otherwise 
unattaiiiahl(>  need. 


Fig.  837. — Liiteml  anastomosis,  Senn's  method. 
Posterior  sutures  introduced  ;  innermost  fixa- 
tion, and  right  apposition  sutures  (0)  looped 
for  tvinir. 


Fig.  838. — Intestinal  anastomosis,  Senn  s 
method.  Plates  approximated  and 
sutures  tied ;  continuous  suture  com- 
pleted. 


Lateral  Anrisfoinosis  with  Potato  Plates  (Dawbaru). — The  employment 
of  potato  plates  for  the  purpose  of  intestinal  anastomosis  presents  the 
surgeon  with  a  material  which  is  common  and  can  be  readily  secured. 
These  desiderata  are  indeed  of  great  importance,  since  they  afford  the 
opportunity  of  quickly  extemporizing  an  agent 
for  an  important  purpose  that  might  be  other- 
wise unattainable  (Fig.  839).  The  potato  plates 
are  made  from  large,  firm,  white  or  sweet  pota- 
toes, preferably  the  latter.  They  are  cut  one 
third  of  an  inch  in  thickness,  about  five  inches 
in  length,  and  of  a  width  that  will  permit  them 
to  slip  easily  into  the  bowel.      After  immersion 

in  tepid  water  for  an  hour  or  two  their  density 

,     .  ^  •  1.1  A  '     Fig.  830. — Lateral  anastomosis, 

is   much  increased,  causing    them  to  assume  a       D^wbarn's  method.     Potato 

boardlike   rigidity.      A    narrow  slit,  about  four       plate,  ligatures  in  place. 


642 


OPERATIVE  SURGERY. 


inches  in  length,  is  then  cut  in  the  center  of  the  long  axis  of  each  plate. 
Eight  nine-inch  coarse  catgut  ligatures,  each  armed  with  a  firmly  fitting 
round  sewing  needle  and  with  large  knots  at  the  distal  ends,  are  provided. 
A  small  retaining  plate  of  rubber  is  then  placed  above  each  knot  by  pass- 
ing the  ligature  through  it.  Through  each  plate  at  the  proper  distances 
four  ligatures  are  passed  and  drawn  into  place  and  the  ends  of  the  needles 
are  then  buried  in  bits  of  potato,  each  about  the  size  of  a  pea.  Seize  the 
distal  needle  with  forceps,  and  pass  it  into  the  open  end  of  the  gut  and 
upward  about  seven  inches;  remove  the  bit  of  jDotato  and  pierce  the  wall 
of  the  intestine  at  a  point  opposite  to  the  mesenteric  attachment  (a) ;  pass 
needles  b  and  c  in  a  similar  manner ;  carefully  adjust  the  plate  by  pushing, 
rather  than  drawing,  into  place  with  the  ligature ;  pass  the  needle  d  and 
make  the  ligature  taut,  as  also  should  be  the  preceding  ones  (Fig.  840). 

The  remaining  plate  and  intesti- 
nal extremity  are  united  in  a 
similar  manner.  If  short  needles 
and  ligatures  are  used  instead  of 
the  long  (Hall),  the  needles  can 
be  placed  in  position  in  the  plate 
before  its  introduction  into  the 
bowel,  and,  after  proper  introduc- 
tion, they  are  pushed  upward  en- 
tirely through  the  plate  and  in- 
testine against  a  resisting  body — 
strip  of  potato — applied  without. 
The  needles  are  then  caught 
with  forceps,  the  ligatures  drawn 
through,  and  the  plate  is  properly 
adjusted.  Dawbarn  regards  this 
modification  as  important,  since 
it  greatly  simplifies  and  hastens 
the  procedure.  The  sutures  are 
now  cleansed  with  a  cloth  wet 
with  antiseptic  fluid,  the  serous 
surfaces  lightly  scraped  with  a  scalpel  to  hasten  union,  and  the  correspond- 
ing sutures  tied  snugly,  beginning  with  the  undermost  one,  as  in  other 
methods.  It  is  not  material  whether  the  open  ends  of  the  intestine  point 
in  the  same  or  opposite  directions  before  the  plate  sutures  are  tied.  A 
Lerabert  suture  should  be  placed  without,  opposite  to  each  plate  suture, 
for  greater  security.  In  fact,  numerous  sutures  of  this  pattern,  or  a  con- 
tinuous one,  may  be  introduced  around  the  borders  of  the  plate  for  a 
similar  reason.  A  narrow,  thin  strip  of  wood  is  now  introduced  into  the 
open  end  of  one  of  the  pieces  of  gut  beneath  the  potato  plate,  and  through 
the  remaining  open  gut  end  the  apposed  intestinal  walls  are  divided  with 
a  sharp-pointed  bistoury  or  scissors  in  a  line  corresponding  to  the  slit  in 
the  plates  down  upon  the  apposing  surface  of  wood  (Fig.  841).  Arrest 
haemorrhage   by   means  of   forceps  passed  through  the  open  ends  of  the 


Fig.  840. — Lateral  anastomosis,  Dawbarn's 
method.  Plate  in  position  and  ligatures 
passed. 


ol'KlJA'l'IoNS   ON    VISCKKA    ( ONN K( "l'KI>    WITH    I'KKITON^UM.     ♦;4:5 

intestiiie,  irrigiito  tlii!   woiiml,  lliiis  clciUi.siii",'  it  and   tt'sliiig  llio  integrity  of 
the  scwini;. 

The  opon  ends  of  the  intestine  nvo  invaginuted  and  closed  by  eontinuouK 
or  interrnpted  sntnres.     Dawbarn  now  a<lvises  the  use  of  curved  swcet-potuto 


l'''i(:.841. — Lateral  juiastoiiHisis.  Dawhui'ii's  method.      Parts  approximated ;  strip  of  wood 
and  the  knife  introduced  to  form  tlie  anastomatic  opening. 

phites,  armed  with  a  ligature  at  either  end,  instead  of  those  just  described 
(Fig.  S-i'-i).  Securer  approximation  when  tied  in  place,  longer  duration  as 
restraining  agents,  and  greater  dispatch  of  application  are  the  chief  claims 
of  advantage  for  this  variety.  It  should  not  be  overlooked,  however,  that 
demands  may  happen  where  sweet  potatoes  are  not  available  for  use. 

The  Remarks. — The  novelty  of  the  proposition  of  the  use  of  vegetable 
plates  and  the  successful  demon- 
stration of  their  utility,  together 
with  the  possible  need  for  their 
employment,  gives  to  them  an 
important  and  definite  position 
in  the  field  of  surgical  endeavor. 
Four  instances  of  use  in  the  hu- 
man subject  of  the  potato  plates, 
with  three  recoveries,  is  the  ex- 
tent of  their  practical  record. 

Lateral  Anastomosis  with 
Segmented  Rubber  Plates  (Rob- 
inson).— According  to  the  de- 
signer, "  take  two  pieces  of  rub- 
ber band,  similar  to  those  used 
in  closing  a  purse  or  a  bundle  of 
papers,  about  two  and  a  half  inches  long  and  three  and  a  quarter  inches 
wide.  For  larger  openings  the  bands  should  be  longer.  Cut  the  corners 
47 


Fig.  842. — Lateral  anastomosis,  Dawbarn's 
amended  method.  Curved  sweet  potato 
plates  in  place. 


644 


OPERATIVE  SURGERY. 


off,  as  shown  in  Figs.  84:3  and  844.  In  the  center  and  at  the  side  of  each 
band  to  be  approximated  cut  out  a  trianguhir  piece,  leaving,  when  the  two 
halves  are  fastened  together  (c,  c),  a  square  aperture  in  the  middle  of  the 
plate.  Cut  out  two  holes  {gg^gg)  at  each  side,  half  an  inch  apart.  The 
holes  are  made  large,  so  that  the  part  of  the  chamois-skin  ring,  to  be 
described,  with  the  linen  thread,  will  easily  pass  through.  From  a  piece  of 
chamois  or  sheepskin  cut  off  several  long  strips,  like  wide  shoestrings,  and 
twist  two  or  three  of  them  together  so  as  to  form  a  ring.  This  ring  [d)  is 
fastened  to  the  plate,  as  shown  in  Fig.  844,  with  catgut  sutures  (c).  Finally, 
loop  six  linen  sutures  (e)  (Barbour,  No.  40),  armed  with  milliners'  needles, 
on  the  ring,  and  the  plate  is  ready  for  use." 

The  openings  into  the  viscera  for  the  purpose  of  introduction  of  the 
plates  should  be  three  and  a  half  to  four  inches  in  length.  A  plate  is 
carried  through  the  opening  into  the  organ  and  the  needles  are  caused  to 


Pig.  843.  Fio.  S44. 

Fig.  843. — Lateral  anastomosis,  segmentod  rubber  plates,  Robinson's  method.  /',  /.  Face 
of  plate,  c,  c.  Stitches  joining  rubber  segments  at  ends,  g,  g,  g.  g.  Lateral  holes 
in  plate  for  sutures,  e,  e,  e,  e,  e,  e.  Sutures  tied  to  chamois  rings,  passing  through 
holes  armed  with  needles.     J,  h.  Sides  of  segment  stitched  to  chamois  ring. 

Fig.  844. — Lateral  anastomosis,  segmented  rubber  plates,  Robinson's  method,  a,  a.  Back 
of  plate,  d,  d.  Chamois  ring  stitched  to  plate  at  c,  r,  c,  c.  e,  e,  e,  e,  e,  e.  Six  su- 
tures armed  with  needles,  each  fastened  to  chamois  ring,  one  passing  between  the 
segments  at  either  end  of  the  plate. 

traverse  its  walls,  at  a  proper  distance  from  the  edge  of  the  incision,  from 
within  outward. 

The  threads  of  the  plates  should  correspond  with  each  other  when  the 
latter  are  in  proper  position,  so  that  when  tied  the  plates  and  tissues  will  be 
properly  adjusted.  The  sutures  are  cut  short,  and  the  union  is  reinforced  by 
Lembert  sutures  placed  at  the  borders. 

Lateral  Anastomosis  by  Sewing  Only. — Abbe  advocates  strongly  the 
abolition  of  all  mechanical  devices  in  intestinal  anastomosis.  He  regards 
union  by  sewing  as  being  the  only  safe  and  reliable  measure.  After 
excision  of  the  intestine  has  been  performed,  invert  the  open  ends  of  the 


Ol'KKA'IMoNS   ON    VISCIllfA    CoNN  IK  "ri:i)    Willi    I'lM;  IION  JU'.M.     ♦;4.j 

divided  liowol,  iiiul  close!  tliciii  with  ;i  ddiihlc  row  of  colored  silk  sutures; 
overlap  the  elosed  extremities  of  the  Ixiwel  four  inches  or  inoro,  or  reverse 
and  place  them  I'ud  to  eiul  as  is  most  convenient ;  unite  the  apposed  surfaces 
by  two  paralK'l  rows  of  contintujus  sutures,  each  four  inches  in  lengtii,  placed 
a  quarter  of  an  indi  apart,  and  introduced  by  means  of  cambric  needles,  each 
armed  with  a  coloi'ed  silk  suture  twentv-four  iiu-lies  in  len<fth,  each  suture 


Kui.  845. — Lateral  aiiiistomosis,  Abbe's   method.      Lower  rows  and   whipstitch  rows  of 

sutures  introduced. 

being  left  at  tlie  end  of  its  row  still  threaded  (Fig.  845) ;  make  a  longitudinal 
opening  into  the  side  of  each  extremity  of  intestine,  about  an  eighth  of  an 
inch  from  the  Hue  of  sewing,  four  inches  in  length;  sew  rapidly  with  over- 
hand stitch  the  borders  of  either  opening  with  a  third  needle  armed  with  a 
long  colored  silk  suture,  which  unites  together  those  margins  already  apposed  ; 
cleanse  the  parts  and  com{)lete  the  union  by  the  continuance  of  the  first  two 
rows  of  sutures  around  the  opposite  unsecured  edges,  thereby  providing  three 
rows  of  sutures  for  the  lower  and  two  for  the  upper  line  of  union  (Fig.  846). 
The  Remarks. — The  primary  rows  of  sutures  should  be  made  about  an 
inch  longer  than  the  proposed  opening  into  the  intestine.  The  Avhipstitch, 
passed  around  the  borders  of  the  respective  openings,  secures  the  proper  rela- 
tions of  the  coat  of  the  intestine  at  these  places,  and  also  arrests  the  bleeding. 


Pig.  846.— Lateral  anastomosis,  Abbe's  method.     Anterior  rows  of  sutures  applied. 

Only  nimble  fingers,  directed  by  much  experience,  can  quickly  and  satisfac- 
torily accomplish  this  form  of  union, 

ILdsteiVs  il/(?///or/.— TIalsted's  method  of  sewing  differs  from  that  of  the 
preceding.     He  employs  the  mattress  suture,  and  introdiux's  but  one  row. 


646 


OPERATIVE   SURGERY. 


The  portions  to  be  anastomosed  are  placed  side  by  side,  and  joined  to 
each  other  b}'  six  or  eight  mattress  sutures  introduced  opposite  the  attach- 
ments of  the  mesentery  (Figs.  847  and  848)  and  tied.    Two  additional  sutures 


Fig.  847. — Lateral  anastomosis,  Halsted's  method.    Posterior  mattress  sutures  introduced. 


Fig.  848. — Lateral  anastomosis,  Halsted's  method.      Posterior  sutures  tied,  incurvation 

sutures  applied. 


^  IT  ^   ir  -K  -^ 


Fig.  849. — Lateral  anastomosis,   Halsted's  method.      All   sutures  tied,  forward  curving 

established. 


are  so  introduced  at  either  end  of  the  preceding  (Fig.  848)  as  to  cause  a  for- 
ward curving  of  the  line  of  approximation  when  tied  (Fig.  849).  The  ante- 
rior row  of  sutures — ten  or  twelve  in  number — is  now  laid,  but  before  tying 


OPERATIONS   ON    VISCKRA    CONNKCTKl)    Willi    I'ERITON/KL'M.     04 7 


are  drawn  apart  {Vi^.  Hl'A)),  and  an  opening  of  proper  size  is  made  at  eitlier 
side  of  the  piiniary  sewinj,'  into  the  intcsline.  The  sutures  are  tlien  tied 
(Fig.  851)  and  the  oiicnition  is  r(ini|ilrtc(l. 


Fiu.  850. — Lateral  anastomosis,  Ilalsted's  iiictliod.     Incisions  maile  and  sutures  laid  fni- 

closing. 


^7^«'?r7r«7:x?rpr^ 


Pig.  851. — Lateral  anastomosis,  llalstcdV  iik-iIkkI.     Anlciiur  row  of  sutures  tied;  opera- 
tion completed. 


Fig.  852.— Lateral  anastomosis,  Maunsell's  metliod. 

The  7^em^//-/!-N\— This  method  is  simpler,  easier,  and  more  quickly  prac- 
ticed than  is  the  preceding.     The  sutures  necessary  for  the  purpose  should 


648 


OPERATIVE  SURGERY. 


be  prepared  in  advance  and  the  needles  threaded  before  operation  begins. 
The  use  of  interrupted  sutures  instead  of  continuous  is  still  another  com- 
mendable measure.  The  submucous  fibrous  coat  is  included  by  the  sutures. 
Maunsell  proposed  the  invagination  of  the  open  ends  of  the  intestinal 
segments  by  means  of  sutures  (Fig.  852)  carri<^d  out  through  the  anastomotic 
opening  (a).  The  extremities  of  the  invaginated  portions  are  tied,  dropped 
into  the  lumen  {b),  the  opening  closed,  and  the  ends  connected  by  a  stitch 
or  two  with  the  contiguous  bowel  {a). 

The  Comments. — It  is  questionable  if  this  be  as  good  or  a  quicker  way 
than  sewing  the  open  ends.     The  final  fixation  sutui'es  are  quite  equal  in  all 
respects  to  those  employed  in  the  common  method  of  closure- 
Lateral  Anastomosis  by  Enterotome  (Grant). — A  blade  of  the  opened 
instrument  (Fig.  853)  is  inserted   into  each  segment  of  intestine  and  the 


Fig.  853. — Grant's  enterotome. 

blades  are  closed,  thus  dividing  the  approximated  wall  and  closely  apposing 
the  peritoneal  surfaces  for  sewing,  which  is  quickly  accomplished  (Fig.  854). 
Eemove  the  instrument,  invaginate  the  open  ends,  and  close  them  by  sewing. 
The  Remarks. — The  instrument  controls  the  tissues  admirably  while  the 
sewing  is  being  done,  and  also  the  bleeding.  It  facilitates  the  procedure  and 
is,  withal,  a  commendable  device.  Wyeth  suggests,  very  properly,  that  the 
incision  should  be  made  not  less  than  four  inches  in  length. 


Fig.  854. — Grant's  instrument,  operation  for  lateral  anastomosis. 

Lateral  Implantation. — Union  by  lateral  implantation  is  the  outcome  of 
imitation  of  the  anatomical  arrangement  at  the  junction  of  the  ileum  and 
colon.     The  end  of  the  smaller  segment  is  treated  as  described  in  Senn's 


UPKKATIONS   ON    VISCKUA   CoNNKCTKI)    Wnil    I'KKITON JIL'M.     (;4D 


Fig.   855. — Liitoral  iinjihintutioii   by  direct  sew- 
ing, or  through  tlio  open  end  of  the  colon. 


method  of  cnd-to-ciid   j()iiunf]f  by  aid   of  the   rubber  bund   (Fig.  708).     A 
longitudimil  slit  id  then  made  in  the  colon  and  a  quilt  stitch  is  introduced 

priniiirily  iit  the  borders  of  the 
slit  (Fig.  855)  or  l)y  the  way  of 
the  open  end  of  the  bowel 
through  either  Ijorder  of  the 
slit,  thence  through  either  .side 
of  the  small  proximal  end  of 
the  gut ;  by  these  means  the 
proximal  end  is  drtiwn  into  the 
large  intestine  in  such  a  manner 
as  to  cause  inversion  of  the  bor- 
ders of  the  opening  in  the  colon, 
thus  bringing  in  contact  with 
each  other  the  serous  surfaces  of 
the  respective  intestines,  which  are  then  joined  by  a  continuous  suture 
applied  at  the  border  of  external  contact  (Fig.  85G).  While  this  method  of 
procedure  is  both  practical 
and  expedient,  it  still  requires 
the  knowledge  of  a  more  ex- 
tended experience  to  establish 
its  absolute  worth. 

If  the  end  of  the  colon  be 
open,  one  can  proceed  as  fol- 
lows :  Pass  long  silk  ligatures 
(four  in  all)  through  the  ile- 
um from  within  outward,  then 
through  into  the  colon,  near 

to  the  edges  of  each  of  these  intestinal  openings  (Fig.  857,  «,  J,  c,  d) ;  tie 
them  firmly,  and  pass  the  ends  through  the  slit  in  the  colon  and  out  through 


Fig.  856. — Lateral  implantation,  union  completed. 


Fi(i.  So 7. 


V\(\.  85S. 


Fig.  857. — Lateral  implantation.  :Maunscirs  method.     a.b.c,d.  Sutures  in  position. 
Fig.  858.— Lateral  implantation.  Maunsell's  method.      a.b,d.   Sutures  carried  through 
open  end  of  colon,     c.  Suture  remaining  behind. 

its  open  end  (Fig.  858,  a,  b,  d) ;  seize  them  with  forceps  and  by  gentle  trac- 
tion invaginate  the  apposed  borders,  causing  them  to  appear  below  at  the  open 


650 


OPERATIVE  SURGERY. 


end  of  the  gut  (Fig.  859) ;  sew  the  borders  us  in  Fig.  803 ;  disinvaginate 
carefully,  close  the  end  of  the  colon,  and  fortify  tlie  line  of  junction  exter- 
nally with  several  sutures  that  in- 
H  elude  the  sero-muscular  coats  of  the 

intestinal  walls  (Fig.  SCO). 


Fig.  859. — Lateral  implantation,  Maun- 
sell's  method.     Borders  invaginated. 


Fig.  860. — Lateral  implantation,  Maun- 
sell's  method.  Openings  closed,  sew- 
ing completed. 


A  choice  of  the  preceditig  measures  will  depend  very  much  indeed  on 
the  skill  and  experience  of  the  operator,  and  the  condition  and  environments 
of  the  patient.  If  the  condition  of  the  patient  demands  rapidity  of  action, 
either  the  Murphy  button,  the  bone  bobbin,  the  bone  or  potato  plates,  or 
Maunsell's  method  can  be  employed,  depending,  of  course,  on  the  prepara- 
tion and  practical  wisdom  of  the  operator.  If  the  time  be  not  pressing, 
and  the  sui'geon  be  favored  with  nimble  and  practiced  fingers,  the  union  by 
sewing  is  the  method  par  excellence  for  adoption.  It  is  impossible,  how- 
evei',  to  indicate  any  one  measure  as  proper  for  universal  employment.  The 
securement  of  the  greatest  good  to  the  greatest  number  invites  and  encour- 
ages the  adoption  of  the  means  best  fitted  for  the  case  in  all  respects. 

Abdominal  Section  for  Wounds  of  Abdominal  Viscera —Penetrating 
wounds  of  the  abdominal  viscera,  due  to  gunshot  and  other  forms  of  violence, 
are  of  frequent  occurrence  in  civil  life.  The  hollow  viscera  suffer  most 
frequently,  and  the  evil  effects  incident  to  their  injury  are  prompt,  pro- 
nounced, and  self-evident.  Ilfemorrhage  due  to  severance  of  important  ves- 
sels, and  peritonitis  dependent  on  the  escape  of  irritating  and  infecting 
agents  into  the  peritoneal  cavity,  are  the  deadly  factors  against  the  influ- 
ence of  which  the  wisest  surgical  contention  so  often  proves  of  but  little  use. 
The  inability  to  promptly  remove  these  agents,  or  master  all  their  influences, 
often  causes  the  efforts  of  the  surgeon  to  appear  useless,  or  even  destructive, 
to  untutored  observation.  However,  the  increasing  number  of  favorable 
results  in  heretofore  hopeless  cases,  following  j)rompt,  aggressive,  aseptic  pro- 
cedure, have  transferred  a  mere  hope  of  success,  based  on  last  resort,  to  the 
field  of  established  surgical  action. 

Abdominal  Section  in  Penetrating  Gunshot  Wounds.— The  early  dangers 
in  this  form  of  injury  relate  to   haemorrhage  and  peritonitis  in  the  order 


Ul'KIfA'I'IoNS    ON    VISCKKA    ('( >NN  KC'I'i;!)    Willi     I'llKIT*  )NJ;iM.     (j.jl 

tneiitioiuHl.  Ila'tnorrha^'o  is  arrested  here  us  in  otlier  parts  of  the  body, 
although  with  <,M-oat('r  ditliciiUy  on  account  of  the  number  and  complexity 
of  the  structures  involved.  l"'nr  the  pr(t})er  treatment  of  this  variety  of 
wound  it  requires,  in  addition  to  thorough  ase])tic  procedure,  a  knowledge 
of  the  point  of  entry  and  the  size  and  direction  of  the  missile,  facts  which 
should  he  carefully  ascertained  before  oi)eration,  if  time  and  o{)portunity  will 
permit.  The  jioiiit  of  entrance  to  the  peritoneal  cavity  is  ascertained  best 
and  safest  by  means  <jf  a  careful  dissection  made  in  the  course  of  the  bullet. 
The  too  common  ])ractice  of  exploration  of  the  wound  with  the  finger  or 
probe  should  be  carefully  emjjloyed  or  avoided  entirely,  since  it  is  frerpiently 
unavailing  and  even  injurious  from  the  first,  and  may  cause  the  introduction 
into  the  walls  of  the  wound  and  into  the  peritoneal  cavity  itself  of  foreign 
bodies  and  infecting  influences. 

The  Abdominal  I/icisioii. — Whether  the  incision  should  be  made  at  the 
median  line  of  the  abdomen  or  at  the  seat  of  the  injury  is  a  matter  largely 
controlled  by  the  situation  of  the  point  of  entry  and  direction  of  the  missile, 
the  presence  of  luernorrhage,  and  also  the  personal  preference  of  the  sur- 
geon. If  symptoms  of  luinnorrhage  be  present,  the  median  incision  offers 
the  best  opportunity  for  the  detection  and  arrest  of  bleeding  points  atid  the 
removal  of  blood  from  the  peritoneal  cavity.  If  the  direction  of  the  abdomi- 
nal wound,  irrespective  of  the  point  of  entry,  indicates  that  the  ball  has 
gone  toward  the  median  line,  the  median  incision  is  indicated.  However,  if 
this  point  be  outside  the  borders  of  the  rectus  abdominis,  and  the  course 
of  the  missile  be  obliquely  outward  in  direction,  instead  of  backward,  up- 
ward, or  downward,  and  symptoms  of  haemorrhage  be  absent,  a  vertical 
incision  at  the  point  of  entry  may  suffice.  Finally,  it  should  not  be  for- 
gotten that  rapidity  of  action  and  unobstructed  observation  are  the  essen- 
tial requirements  for  the  prompt  detection  and  arrest  of  bleeding  points,  as 
well  as  for  the  detection  and  closure  of  intestinal  wounds.  Therefore,  an 
embarrassing  or  ineffective  incision  should  be  promptly  supplemented  by  a 
better  one  when  circumstances  will  permit.  In  either  instance  the  incision 
should  be  of  sufficient  length  and  so  directed  as  to  facilitate  the  require- 
ments of  the  procedure.  The  borders  of  the  incision  are  held  widely  apart 
by  means  of  suitable  retractors  or  by  traction  sutures  passed  through  their 
entire  thickness. 

Ordinarily  the  free  separation  of  the  borders  exposes  to  view  the  omen- 
tum marked  with  evidences  of  traumatism,  as  exhibited  by  the  presence  of 
extravasated  blood,  and  perhaps  of  bleeding  points.  If  the  wound  be  a  sim- 
ple one,  the  bleeding  points  are  closed  by  silk  ligatures  and  the  omentum  is 
turned  aside  so  as  to  expose  to  view  the  blood,  escaped  intestinal  contents, 
and  intestinal  wounds  that  may  be  contiguous  to  it.  Blood  and  foreign  mat- 
ter tlius  exposed  should  be  carefully  removed  by  wiping  with  soft  sponges, 
which  are  changed  or  thoroughly  cleansed  after  each  act. 

T7ie  Detection  and  Arrest  of  H(emorrhage. — Ordinarily  any  considerable 
haemorrhage  will  have  ceased  before  the  opportunity  for  operation  arrives, 
either  by  Nature's  efforts  or  the  death  of  the  patient.  If  there  be  reason  to 
believe  that  dangerous  bleeding   still   continues,   prompt   measures  for  its 


652  OPERATIVE  SURGERY. 

an-est  should  be  instituted.  On  the  other  hand,  if  only  insignificant  bleed- 
ing be  present,  the  examination  for  intestinal  wounds  should  begin  at  once, 
and  the  bleeding  points  should  be  arrested  as  soon  as  found.  The  search  in 
the  abdominal  cavity  for  bleeding  vessels  and  the  control  of  haemorrhage  is  a 
perplexing  matter,  especially  if  the  demand  be  urgent  and  intestinal  wounds 
be  apparent  and  for  the  time  irremediable.  I  am  disposed  to  advise  that 
pressure  upon  the  aorta,  by  means  of  the  hand  passed  upward  through  the 
wound  to  the  diaphragmatic  opening  for  that  vessel,  should  be  made  at 
once  in  such  cases  to  arrest  the  haemorrhage ;  and,  if  admissible,  that  the 
pressure  be  maintained  until  the  intestinal  wounds  are  at  least  temporarily 
closed,  after  which  the  bleeding  points  can  be  secured  without  the  danger  of 
further  peritoneal  infection  from  this  source. 

Haemorrhage  from  wounds  of  the  stomach,  intestines,  mesentery,  and 
serous  surfaces  generally,  can  usually  be  well  controlled  by  means  of  large, 
fine  sponges  pressed  firmly  into  place  and  held  there  by  the  hand  of  an 
assistant,  while  the  surgeon  cautiously  releases  them  in  order  from  below 
upward,  catching  and  closing  the  bleeding  points  with  fine  silk  thread  as 
they  appear.  The  bleeding  points  can  be  secured  by  direct  ligation  as  in 
other  tissues  of  the  body,  or  by  transfixion  and  tying,  transfixion  being  the 
more  expedient  in  mesenteric  wounds.  In  the  latter  instance,  however,  the 
inclusion  of  vessels  other  than  the  injured  one  may  cause  localized  gangrene 
of  the  intestine.  Miirpliy  has  demonstrated  on  dogs  the  importance  of 
their  parallel  artery  (page  G54).  If  haemorrhage  be  due  to  injury  of  the 
solid  viscera,  the  expedients  of  relief  will  be  somewhat  different  and  like- 
wise tirgently  demanded.  Haemorrhage  from  the  liver  is  arrested  either  by 
closure  of  the  wound,  by  sewing,  by  actual  cautery,  or  by  tamponing  with 
iodoform  gauze  ;  the  spleen  and  kidney  may  be  treated  in  a  similar  manner, 
or  the  bleeding  points  clamped  for  temporary  control  and  the  wounded  organs 
removed  later,  if  necessary,  for  the  arrest  of  haemorrhage. 

The  Search  for  Intestinal  Wounds. — The  search  for  intestinal  wounds 
must  be  conducted  with  great  caution,  and  with  the  aid  of  a  good  light 
(Figs.  103  and  861,  o),  otherwise  one  or  more  may  pass  unobserved  ;  and 
faecal  infection,  due  to  escape  of  intestinal  contents,  will  follow  incautious 
handling.  After  proper  control  of  hemorrhage,  the  loop  of  intestine  nearest 
the  point  of  peritoneal  perforation  is  carefully  raised  and  examined,  begin- 
ning at  the  part  of  the  intestine  farthest  from  the  course  taken  by  the  mis- 
sile, passing  along  and  closing  each  opening  as  soon  as  found  with  a  suitable 
clamp  (Fig.  861,  h  and  h),  or,  better  still,  perhaps,  securing  them  for  the  time 
with  pressure  forceps,  and  giving  them  in  charge  of  an  assistant.  Any  infect- 
ing material  or  blood  sliould  be  wiped  away  as  soon  as  noted.  If  it  be  neces- 
sary to  remove  the  intestine  from  the  abdomen  for  examination,  it  should  be 
quickly  surrounded  with  rubber  tissue  covered  with  aseptic  gauze  saturated 
with  hot  saline  solution,  and  kept  thus  protected  until  returned. 

The  Comments. — If  the  escape  of  intestinal  contents  has  already  hap- 
pened in  a  considerable  degree,  a  gentle  stream  of  the  saline  solution  is 
caused  to  flow  continuously  across  the  examination  field,  thus  washing  away 
at  once  the  obnoxious  products.     The  passage  of  some  of  the  fluid  between 


ui'Ki:ati()N.s  on  visckua  cunnkctkd  wrrii  ri:RiTONj;L'M.    053 

intestinal  folds  need  not  bo  rep^arded  with  fear  of  further  iiifc(^tion,  for  in 
such  cases  abdominal  irri<,'ation  is  conimoidy  employed  as  a  protective  meas- 
ure; and,  too,  the  warmth  of  the  lluid  exercises  u  salutary  elTect  on  the 
injuretl  tissues  and  on  the  patient  as  well.  We  are  of  the  oj)inion  that  it 
is  better  to  temporarily  close  the  openings  than  to  treat  them  finally  as  soon 
as  found.  By  the  former  method  they  are  secured  before  the  height  of  peri- 
staltic action,  excited  by  the  exposure  and  handling,  is  attained.  This  is  a 
manifest  advantage,  since  the  peristalsis  not  only  changes  the  comparative 
relations  of  the  openings,  but  also  causes  further  escajie  and  dissemination 
of  infecting  agents.  To  each  of  the  retaining  clamj)s  a  string  should  be 
attached,  one  end  remaining  without,  to  serve  as  a  guide  to  the  intestinal 
wounds.  If,  after  securing  the  openings,  the  condition  of  the  patient  will 
warrant,  it  is  better  to  eliminate  at  once  from  the  peritoneal  cavity,  by  means 
of  hot  saline  or  sterilized  fluids,  all  bkx^d  clots  and  infecting  matter,  rather 
than  to  risk  the  danger  of  more  extended  dissemination  of  these  products,  due 
to  increased  peristalsis  and  unavoidable  manipulation.  It  is  difficult  indeed 
to  express  the  proper  degree  of  haste  to  be  exercised,  except  by  saying 
that  each  case  must  be  treated  in  accordance  with  its  own  demands,  always 
remembering  that  an  undetected  perforation  will  of  itself  almost  certainly 
destroy  the  patient.  During  the  handling  of  the  intestine,  the  coils  adja- 
cent thereto  should  be  carefully  protected  from  all  deleterious  influences  by 
broad  aseptic  sponges  and  pads,  or  abundant  aseptic  gauze. 

The  average  number  of  perforations  in  a  gunshot  wound  of  the  intestines 
is  between  five  and  six.  Contused  and  lacerated  gunshot  wounds  of  the 
bowel  require  the  same  consideration  as  the  penetrating.  Tlie  use  of  hydro- 
gen gas  for  the  discovery  of  intestinal  perforations  is  strongly  advocated  by 
Senn.  In  common  with  many  others,  the  author  is  not  disposed  to  advise 
its  employment  in  the  general  manner  advocated  by  that  eminent  surgeon. 
The  intestinal  distention  thus  caused,  together  with  the  liability  of  extrusion 
into  the  peritoneal  cavity  of  infecting  intestinal  agents,  may  be  regarded  as 
strong  objections  to  this  method  of  practice.  However,  the  author  can  com- 
mend its  employment  when  it  is  addressed  to  a  limited  portion  of  the  intes- 
tinal tract,  for  the  purpose  of  detecting  not  the  first,  but  rather  the  last, 
or  as  yet  an  undiscovered  perforation. 

The  Repair  of  the  Intestinal  Woinids. — The  proper  repair  of  the  intes- 
tinal wounds  requires  an  anatomical  knowledge,  at  least,  of  the  visceral 
attachment  of  the  mesentery.  The  two  layers  of  the  mesentery  separate  as 
they  approach  the  jejunum  and  ileum,  forming  a  triangular-shaped  space 
about  three  fourths  of  an  inch  long,  with  a  base  about  a  fourth  of  an  inch 
wide,  which  is  formed  by  the  uncovered  muscular  coat  of  the  intestine. 
This  space  contains  fat,  delicate  fibrous  tissue,  and  the  vessels  and  nerves  of 
the  intestine  (Fig.  811).  If  care  be  not  taken  in  sewing  the  intestine  at  the 
mesenteric  border  (Fig.  811),  especially  in  the  use  of  the  Lenibert  suture,  im- 
perfect apposition  of  the  borders  at  that  point  will  be  followed  by  the  escape 
of  intestinal  contents  into  the  triangular  space  and  thence  into  the  peritoneal 
cavity.  The  terminal  parallel  branches  of  the  superior  mesenteric  artery 
are  found  here,  each  running  directly  to  a  more  or  less  independent  area 


654  OPERATIVE  SURGERY. 

of  intestinal  distribution,  the  shortest  branches — one  third  of  an  inch  long 
— being  at  the  termination  of  the  ileum.  Since  these  branches  arise  from 
the  final  loops  of  the  mesenteric  artery  and  are  comparatively  independent 
of  each  other,  the  loops  should  be  treated  with  great  consideration,  other- 
wise the  nutrition  of  the  intestine  may  be  impaired.  Murphy  has  shown 
that  the  parallel  artery  of  the  dog's  bowel  will  nourish  for  forty-eight  hours 
six  and  a  half  inches  of  intestine  when  the  straight  branches  that  supply 
it  are  tied.  However,  if  the  circulation  of  this  and  the  corresponding 
straight  terminal  vessels  be  arrested  by  ligature,  gangrene  of  the  intestine 
will  ensue  if  the  circulation  of  more  than  half  an  inch  of  the  intestine  be 
involved. 

The  thickness  of  the  muscular  coat  of  the  intestine  varies  in  different 
subjects  and  in  different  parts  of  the  organ,  being  thickest  at  the  upper  part 
of  the  jejunum — one  twentieth  of  an  inch — and  thinnest  at  the  lower  portion 
of  the  ileum — one  fortieth  of  an  incii.  The  submucous  fibrous  tissue  is  an 
important  element  of  strength  in  sewing,  since  it  is  tough  and  impervious  to 
air  or  water.  The  importance  of  including  it  within  tlie  stitch,  and  its 
proximity  to  the  mucous  membrane  and  glands  within  the  intestine,  empha- 
size the  necessity  of  cautious  technique  in  sewing,  to  obviate  involvement  of 
the  intestinal  lumen.  Cambric  needles  armed  with  colored  silk  should  be 
employed  for  intestinal  sewing  (Fig.  861,  e).  These  needles  separate  rather 
than  sever  the  tissue,  thereby  limiting  the  liability  to  hemorrhage,  and  provid- 
ing a  small,  firm  stitchhole.  The  use  of  colored  silk  enables  the  surgeon  to 
quickly  distinguish  the  sutures  and  the  silk  thread  as  well.  Fine  aseptic 
thread  of  any  variety  of  texture  can  be  employed  in  cases  of  emergency. 

The  special  importance  of  the  intestinal  wounds  relates  to  their  nature, 
size,  contiguity,  and  situation.  Lacerated  and  contused  wounds  characterize 
gunshot  injuries  of  the  intestine.  If  the  impingement  be  but  trifling,  a  con- 
tusion is  caused;  if  greater,  laceration  ensues  with  or  without  penetration; 
if  the  latter  happen,  the  intestinal  mucous  membrane  protrudes.  Size  and 
contiguity  are  important  elements,  since  w^ounds  of  large  size  and  contiguous 
to  important  structures  often  require  sterner  measures  of  treatment  than  do 
their  antitheses.  The  situation  of  the  intestinal  wound  is  of  major  impor- 
tance, and  often  measures  the  distance  between  simple  expeditious  operative 
procedure  and  the  reverse  of  this  practice. 

Ln  the  repair  of  the  i)ifestinal  wounds  a  strict  aseptic  rer/iuie  must  be 
practiced  :  abundant  sponges,  gauzes,  iodoform,  hot  saline,  and  medicated 
solutions  must  be  prepared  and  at  hand.  Xumerous  aseptic  towels  moist- 
ened with  antiseptic  fluids  should  eiiviron  the  immediate  seat  of  the  opera- 
tion and  be  changeil  whenever  soiled.  It  may  be  well  to  repeat  that  vigor- 
ous sponging  of  a  serous  surface,  and  the  application  thereto  of  strong  solu- 
tions of  corrosive  sublinuite  or  carbolic  acid,  produce  a  traumatic  effect  on 
the  epithelium  which  not  only  provokes  inflammatory  action,  but  impairs 
the  physiological  functions  of  serous  structures,  thus  hastening  the  onset  of 
deleterious  processes  and  weakening  the  power  of  resistance  and  restora- 
tion. The  portion  of  intestine  undergoing  repair  is  isolated  by  means  of  soft, 
flat  sponges  wet  with  the  hot  saline  sohition,  or  by  gauze  pads  (Fig.  GG)  simi- 


()|'K|{A'I"I(>.NS   ON     \IS(i:i{A    (MlNNKcrKD    WII'll    IMMU'l'oN  .MUM.     055 


Fic.  8fil. — Instniinpiits  employed  in  intestinal  repair. 

a.  Scalpel  and  bistouries,  h.  Forcipressure.  c.  Needle  forcej)s.  d.  Scissors,  e.  Needles 
threaded  with  colored  silk.  /.  Rubber  tissue  around  wicking  for  drainage,  and  a 
piece  of  rubber  tissue.  /(.  Glass  and  rubber  drainage  tubes,  i.  Sponge-holder. 
_/.  Tenacula.  k\  Clamps  for  intestinal  openings.  I.  Dissecting  and  mouse-tooth 
forceps.  t».  Rubber  band  and  catgut,  h.  Sponge  with  string  attachment,  o.  Elec- 
tric light.     Openings  are  cut  in  drainage  agents  to  suit  the  operator. 


656 


OPERATIVE  SURGERY. 


larly  treated.  A  weak  antiseptic  solution  may  be  used  instead.  Infecting 
agents  are  carefully  wiped  away  by  a  soft,  clean  sponge ;  the  intestinal  con- 
tents are  pressed  away  from  the  opening  and  retained  by  agents  devised  for 
the  purpose  (Fig.  868),  or  by  the  thumbs  and  fingers  of  the  surgeon,  or  by 
an  assistant  (Fig.  871),  who  thereafter  carefully  holds  the  intestine,  with  the 
lumen  compressed,  in  a  convenient  manner  for  the  operator. 

After  inversion  of  the  protruding  lips  of  the  wound,  penetrating  wounds, 
at  all  aspects  of  the  intestine  except  the  mesenteric  border,  can  be  properly 
closed  by  the  continuous  suture  of  Dupuytren  or  Cushing  (Figs.  782  and 
78(3),  the  latter  being  the  more  hidden  when  drawn  in  place.  The  inter- 
rupted sutures  of  Lembert  (Fig.  802)  and  Halsted  (Fig.  793),  while  equally 

efficient,  are  less  quickly  applied  than  the  con- 
tinuous varieties.  Interrupted  sutures  are 
placed  from  a  sixth  to  a  tenth  of  an  inch 
apart,  and  should  include,  like  the  other  va- 
rieties, the  submucous  fibrous  tissue  of  the 
bovvel.  Not  infrequently  two  rows  of  sutures 
are  applied ;  the  first  is  interrupted,  the  last 
is  usually  continuous,  and  penetrates  the  tis- 
sues less  deeply  than  the  former,  which,  when 
tightened,  it  entirely  obscures.  After  closure 
the  surface  is  sopped  clean  with  the  saline 
fluid  or  sterilized  water,  and  a  small  amount 
of  iodoform  is  sometimes  applied  with  the 
finger  along  the  line  of  union.  The  contused 
wounds  should  be  treated  in  the  same  manner 
as  lacerated  wounds,  because  the  contused 
portion  is  liable  to  slough  and  expose  the 
patient  to  peritonitis  and  all  of  its  dangers.  Either  longitudinal  or  trans- 
verse closure  of  an  intestinal  wound  can  be  practiced ;  the  former,  how- 
ever, should  not  be  employed  at  the  mesenteric  border,  or  elsewhere  when 
the  lumen  of  the  bowel  is  reduced  by  the  sewing  to  less  than  one  half 
of  its  normal  size  (Senn).  Transverse  sewing  interferes  with  the  nutri- 
tion of  the  bowel  less  than 
the  longitudinal,  especially 
when  contiguous  to  the 
mesenteric  border.  If  this 
border  or  the  mesentery  be 
wounded  so  as  to  destroy  the 
circulation,  resection  of  the 
intestine  corresponding  to 
the  seat  of  the  injury  must 
be  practiced  on  account  of  the  imminent  danger  of  sloughing.  A  limited 
injury  may  be  repaired  by  transverse  sewing,  supplemented  perhaps  by  the 
union  of  the  ends  and  borders  of  a  longitudinal  incision  (Fig.  863),  so  as  to 
cause  moderate  bending  or  elbowing  of  the  gut  (Fig.  804).  If  a  large  open- 
ing, or  a  slough,  or  numerous  contiguous  injuries  of  this  nature  be  present 


Fig.  iHJ2. — Lenibert's   inten-u{)ted 
suture. 


Fig.  86.3.- 


-Longitudinal  division  of  transverse  defect. 
Sutures  placed  for  union. 


Ol'KUATlDNS   UN    VlhCKUA   CUNNHCTED    Wl'l'll    I'KKI'n  »N  JIUM.     O^J 


at  tlie  free  border  of  the  intestine  (Fig.  8G5),  proper  rejuiir  ciiii  be  coiisuin- 
mated  bv  tlie  process  of  '' elbowiiig  "  (eiiteroi)liisLy,  luige  <i?:}),  either  with  or 

without  removal  of  the  damaged 
tissue.  All  incision  two  or  more 
inciies  in  hMigth,  according  to 
the  area  of  the  injury,  is  made 
lengthwise  iu  the  gut,  the  cen- 
ter corresponding  to  that  of  the 
Ficj.  864.— TniiisvLr.se  sowinj::  for  repjilr  of  (k'foct.  injui-y  (p^jg.  803).  The  latter  is 
Lou'Mtiuliiial    division  of   defect  turned  in,     . ,  '      '  ■      i      .      -^i  -i        r 

eaiisiii- sliglii  elbowing.  then   repaired   at  either  side  of 

the  incision  by  sewing  (Fig.  86G), 
after  whicli  tlie  bowel  is  bent  or  "  elbowed,"  so  as  to  bring  corresponding  por- 
tions of  the  longitudinal  incision  in  contact  with  ea(!h  other,  in  which  posi- 
tion they  are  united.     This  plan  turns  the  defects  inward  and  still  niain- 


FlG.  865. — Repair  by  decided  elbowing,     a,  b,  c.  Borders  of  defects  trimmed. 

tains  a  proper  sized  lumen,  thus  obviating  the  necessity  of  resection  of  the 
intestine,  a  manifestly  dangerous  alternative  in  the  presence  of  inexperience 
and  pressing  demand.  Elbowing  should  not  be  practiced  at  the  mesenteric 
border  on  account  of  the  operative  difficulty,  the  danger  of  sloughing  attend- 
ing it,  and  also  the  liability  of  subse- 
quent kinking  of  the  gut,  none  of 
which  conditions  are  pronounced  in 
convex-border  elbowing. 

Chaput  advised  stitching  over 
the  area  of  an  impending  perfo- 
ration the  surface  of  a  contiguous 
intestine.  This  is  an  ingenious 
proposition,  and  may  no  doubt  prove 
effective  under  special  contributing 
circumstances. 

In  wounds  of  the  omentum  and 
mesenteric  haemorrhage  is  arrested, 
the  borders  of  the  wound  are  in- 
verted, and  the  opening  is  closed  by 
sewing.     If  the  omentum  be  greatly 


Fig.  866.— Repair   by    decided   elbowing. 
a,  b,  c.  Borders  in  position  for  sewing. 


658 


OPERATIVE   SURGERY. 


damaged,  or  if  it  and  the  mesentery  are  infiltrated  with  blood,  the  omen- 
tum is  removed  above  the  seat  of  injury  after  ligature  with  silk,  and  the 
wound  of  the  mesentery  is  closed  after  the  evacuation  of  the  extravasated 
blood  and  the  arrest  of  haemorrhage. 

Resection  of  the  Small  Intestine  (Enterectomy). — In  those  cases  in  which 
the  injury  is  too  extensive  to  admit  of  simple  means  of  repair,  or  the  circu- 
lation of  the  mesenteric  border  is  destroyed,  or  extensive  disease  has  taken 
place,  etc.,  the  removal  of  a  portion  of  the  intestine  becomes  necessary.  The 
amount  to  be  removed  may  vary  from  half  an  inch  to  many  feet.  In  cases 
of  multiple  injury  of  the  intestine,  it  is  wiser  to  perform  a  single  enterec- 
tomy, even  though  a  limited  amount  of  uninjured  intestine  be  sacrificed, 
than  to  practice  double  enterectomy  with  the  view  alone  of  saving  a  greater 
amount  of  intestine,  for  the  unfavorable  influence  of  time  and  exposure  on 
the  final  outcome  of  the  case  is  of  greater  significance  than  the  sacrifice  of 
the  intervening  uninjured  portion  of  the  bowel. 

The  resection  of  intestine  is  not  a  difficult  procedure,  but  the  repair  of 
the  resulting  wound  is  quite  another  matter.  Milliners'  needles  (Fig.  861,  e), 
with  points  sufficiently  blunted  to  permit  easy  recognition  of  the  piercing  of 
the  submucous  fibrous  coat,  armed  with  fine  twisted  aseptic  colored  silk,  are 
the  best  for  sewing.  When  circumstances  will  permit  two  lines  of  sutures 
are  usually  employed,  one,  the  interrupted,  the  other  the  continuous  variety, 
the  last  of  which  is  outermost  and  properly  causes  concealment  of  the  for- 
mer. Differently  arranged  sutures  used  combinedly  give  greater  security 
than  does  the  like  use  of  similar  ones.     TJie  ijiterrnpted  sufufe  pennits  dis- 


FlG. 


57. — The  effect  of  distention  on  union  with  interrupted  suture, 
tention.     b.  After  additional  sutures  added. 


a.   Before  dis- 


tention at  the  seat  of  sewing  (Fig.  8G7),  the  continuous  hinders  it ;  the  inter- 
rupted contributes  but  little  to  contraction,  the  continuous  much,  unless 
great  care  be  exercised  in  the  introduction ;  the  integrity  of  the  union  by 
the  interrupted  is  often  practically  affected  by  changes  in  caliber  of  the  gut, 
that  of  the  continuous  is  made  insecure  by  subsequent  contraction  ;  infection 


OI'KKATIONS    ON    NlSCKllA    f  UNN  KCTED    WITH    I'KIUTON  .KL'.M.     05U 

by  c';ij)illiiiity  is  liniitctl  in  tlie  interrupted  to  perhaps  n  sin<,'Ie  stitch,  in  the 
continnniis  it  may  invade  the  entin;  U'n<,'th  ;  interrupted  stitehes  are  east  olT 
independi'ntly  of  eadi  other,  tht;  continiioiis  suture  remains  until  the  fiiuil 
stiteii  is  liberated. 

It  is  apparent,  thcrcfoi'e,  tliat  tiu'se  varieties  serve  well  together  ami  that 
the  continuous  suture   should   he  applic(l  hist.      The  jtu-hing  aside  of  the 


Fig.  868. — Means  employed  to  restrain  intestinal  contents,  a.  Self-closing  forcep.?, 
blades  protected  by  rubber  tubing,  b.  liillroth's  clamp,  c.  Murphy's  clamp,  d. 
Maunseil's  safety  pin  and  sr)onge  clamp,  e.  Jeannel's  rubber  tube  and  forcipressure 
clamp.    /.  Ileinake's  clamp,    g.  McLaren's  clamp. 

contents  of  the  intestine  and  the  prevention  of  the  return  during  re])air  are 
matters  of  great  importance.  This  purpose  can  also  be  accomplished  by 
means  of  narrow  strips  of  iodoform  gauze  ])assed  around  the  gut  through  an 
opening  made  at  the  border  of  the  mesentery,  and  tied.  Rubber  bands  (Fig. 
878)  may  be  employed  in  a  similar  manner  (Senn),  Flat  pieces  of  sponge 
wrapped  around  the  gut  and  having  their  ends  pinned  together  with  a  safety 
pin  passed  so  as  to  include  the  border  of  the  mesentery  (Mauusell)  (Fig. 
8(J8,  d),  are  efficient.  Finally,  though  less  effective  and  convenient,  the 
fingers  and  thumbs  of  an  assistant  may  be  called  into  use  for  this  purpose 
( Fig.  871).  Various  measures  are  advised  to  properly  control  the  extremities 
of  the  intestine  during  the  act  of  sewing.  The  introduction  of  traction  loops 
at  points  a  short  distance  from  the  respective  eiuls  (Fig.  8G9),  in  such  a 
manner  as  to  cause  parallel  ridges  through  which  the  needle  can  be  readily 
passed,  is  an  effective  and  ever  available  means. 

Koc]ter\s.  Method  of  Rejection. — Draw  well  out  of  the  peritoneal  cavity 
the  portion  of  intestine  to  be  removed,  exposing  healthy  intestine  for  a  con- 
48 


660 


OPERATIVE  SURGERY. 


venient  distance  at  either  end  of  the  impaired  part;  pack  carefully  around 
the  exposed  bowel  soft  sponges  or  gauze  saturated  with  the  hot  saline  solu- 
tion, so  that  any  further  j^erito- 
neal  infection  will  be  prevented  ; 
press  away  from  the  resection 
area  with  the  thumbs  and  fingers 
the  intestinal  contents,  and  at 
the  limits  of  displacement  apply 
suitable  clamps  (Fig.  870)  to  the 
intestine  at  right  angles  with  it 
or  with  outward  divergency  (Fig. 
870,  b,e)  so  as  to  obstruct  the  lu- 
men of  the  gut  and  prevent  the 
return  of  the  contents  to  the  evac- 
uated area.  Divide  the  intestine 
at  right  angles  with  its  long  axis 
or  with  slightly  outward  diver- 
gence through  well  -  nourished 
structure  at  points  about  three 
quarters  of  an  inch  inside  the 
clamps  with  blunt-pointed  scissors ;  sever  the  mesentery  from  the  wall  of 
the  bowel  with  scissors  passed  along  the  base  of  the  interperitoneal  triangu- 


irt;  |i|T 


lilA. 


Fig 


869. — A  method  of  control  of  the  ends  in 
intestinal  sewine:. 


Fig.  870. — Resection  of  the  small  intestine,  Koeher's  method,      a.  Line  of  division  of 
omentum,     d.  Sutures  applied,     b,  e.  Oblique  line  of  section,     c.  Diseased  area. 

lar  space,  catching  the  bleeding  points  as  they  appear,  thus  relieving  the 
excised  portion  from  its  attachments  and  allowing  it  to  fall  away  with  each 


ol'Ki:  A'l'loNS   (>.\    VISCKKA    ( OXN  KC'I'KI »    Willi     I'I:HIT()N^<:UM.     f.Ol 


cxtrcinit}'  seciiroly  clamiic'd.  Cleanse  the  j)arts  tliuruuglily,  substitute  fresli 
packings,  ligature  tlie  mesenteric  vessels,  and  turn  in  und  sew  witli  con- 
tinuous suture  the   border  of  tlic  mesentery  (l''i.i,'.  ^^T*')-      Then  bring  tiie 


Fig.  871. —  Resection  of  intestine,  Koclier's  method,     b.  Tied  border  of  mesentery,     a. 
First  fixation  suture,     c.  Second  fixation  suture.     (/.  Posterior  continuous  suture. 

ends  of  tlie  divided  bowel  near  together,  pass  a  fixation  suture  through 
the  sites  of  mesenteric  attachment  of  both  (a),  and  another  through  the 
opposite  borders  at  their  extremities,  to  secure  accurate  apposition  of 
corresponding  parts  of  the  intestine  {<•).  The  fixation  sutures  do  not  pass 
through  the  intestinal  wall, 
but  include  the  serous  and 
muscular  structures  of  the 
intestine  only,  and  when 
pulled  on  in  opposite  direc- 
tions closely  approximate  the 
divided  ends  throughout.  A 
continnous  sewing  (fixation) 
is  now  begun  at  the  mesen- 
teric border,  including  the 
entire  thickness  of  the  intes- 
tine, and  taking  a  wider  grip 
of  the  serous  than  of  the 
mucous  layer  (Fig.  8T1).  The 
first  loop  of  the  suture  is 
tied  and  the  passive  end  left 
long  for  subsequent  use  (d). 
Then,  beginning  behind,  the 


Fiii.  873. — Resection  of  intestine,  lontritudinal  section, 
Kocher's  method.  a.  Anterior  serous  suture 
knotted,  b.  Posterior  serous  suture  knotted,  c. 
Deep  suture,  mesenteric  attachment,  d.  Deep 
suture,  free  border. 


662 


OPERATIVK  SURGERY. 


borders  of  the  gut  are  united  firmly  together  by  a  continuous  suture  formed 
of  the  remaining  end  of  the  loop,  and  passing  through  the  entire  thickness 
of  the  walls  of  the  divided  ends  around  their  entire  circumference,  finally 
being  tied  with  the  passive  extremity,  thus  firmly  and  securely  closing  the 
intestinal  canal.  Cleanse  the  line  of  suturing  and  also  the  exposed  intestine, 
and  provide  fresh  packings  if  necessary.  Then,  commencing — knotting,  as 
before — at  the  convex  border  [b,  Fig.  872),  introduce  an  external  posterior 
suture  along  the  line  of  the  deep  one,  including  the  serous  and  muscular  coats 
only,  tying  it  finally  to  the  passive  extremity  of  the  anterior  suture  (Fig. 
8T2.a).  Then  introduce  anterior  suture,  tying  to  free  end  (b).  The  opening 
in  the  mesentery  is  closed  by  sewing  together  its  borders,  or  by  folding  and 
stitching  in  place.  The  parts  are  then  cleansed  with  hot  saline  solution, 
packing  is  removed,  and  the  intestines  are  returned  to  the  abdominal  cavity. 
Although  the  mucous  membrane  protrudes  freely  after  division  of  the  in- 
testine, the  protrusion  should  not  be  trimmed.  The  first  row  of  sutures 
may  include  only  the  mucous  membrane  itself,  the  continuous  form  being 
preferable  there.  Two  additional  external  rows  are  often  applied,  the  first 
the  interrupted,  the  second  and  final  the  continuous  form.  If  the  patient's 
condition  requires  prompter  action,  the  last  two  only  need  be  employed. 


"» 


,  J"!   :;:r    ';|i^ 


Fig.   873. — Eeseetion  of  intestine,  Halsted's  method.     Rubber  bands  and   presection 

sutures  in  position. 

HaUteiVs  Method  of  Resection. — The  portion  to  be  resected  is  isolated  as 
in  the  preceding  instance,  and  the  contents  are  pushed  aside  and  retained  by 
rubber  bands  carried  around  the  intestine  and  fastened  by  looping  (Fig.  873). 

The  lines  of  incision  are  so  di- 
rected as  to  secure  for  each  end 
of  the  bowel  free  arterial  supply 
which  is  carefully  protected 
throughout  from  injury.  Before 
removal  is  begun  "  presection  "  su- 
tures, usually  six  in  number,  are 
introduced,  just  outside  of  the 
^  '^  proposed  lines  of  division  in  the 

■  .      ^  manner  indicated  in  the  illustra- 

„      ar-A     T.        •        t      ,.   ..■       TT  1  *^  T      tion.       These    sutures    serve    to 
Fig.  874 — Resection   of  intestine,   Halsteds  .  i       /tt  \ 

method.    Presection  sutures  tied.  bring  the  ends  together  (Fig.  8y4), 


(M'KILVTIONS   ON    VISCKRA    (•oNNKC'l'KU    Wl'lJl    rKKlTON.ia'M.     »;«;3 

thereby  facilitating  the  fnml  sewing.     The  mattress  sutures  are  now  intro- 
tluceil,  piiTciiig,  but  not  passing  through  the  submucous  librous  coat,  and 


'\.      X-",," 


Fi(i. 


876. — Re?:ection   of  intestitie,   Halsted's 
method.     Sutures  tied. 


Kiii.  875. — Resection  of  intestine,  llidsled's  nielhud.     Jlal^ted's  mattress  sutures  placed. 

tied  (Fig.  875).  The  slit  in  the  mesentery  is  cautiously  closed  so  as  not  to 
impair  the  vascular  su})ply  of  the  intestinal  extremities  (Fig.  8T'>).  llalsted 
advises  that  the  sewing  be  done 
over  a  rubber  bag  which  is  intro- 
duced between  the  "  presection  " 
sutures  and  carefully  inflated. 
He  claims  for  this  measure  the 
attainment  of  a  higher  order  of 
work. 

Some  years  ago  Treves  devised 
a  plan  akin  to  this  which  he  sub- 
sequently discarded.  For  further 
description,  see  Philadelphia  Med- 
ical Journal,  January  8,  1898. 

Harris's  Method  of  Circular  Enterorrlinphij. — After  resection  of  the 
desired  portion  and  proper  isolation  and  cleansing  of  the  parts,  Harris  unites 
the  divided  ends  in  the  following  ingenious  manner  :  Tiiread  each  of  three 
needles  with  fine  silk ;  remove  the  mucous  membrane  from  the  distal  end  of 
the  gut  for  about  three  fifths  of  an  inch  with  a  sharp  curette,  being  sure  to 
destroy  the  glands  ;  transfix  at  one  side  of  the  mesentery  at  the  inner  limit 
of  denudation  the  denuded  end  of  the  bowel  with  a  needle ;  cause  the  point 
of  the  needle  to  project  from  the  caliber  of  the  bowel  a  little  beyond  the  free 
edge  (Fig.  8TT) ;  pick  up  transversely  with  the  point  of  the  needle  (fl),  just 
to  one  side  of  the  mesentery,  close  to  the  proximal  end  of  the  bowel,  a  por- 
tion of  its  wall ;  draw  the  needle  back  slightly,  and  turn  the  point  backward 
and  round  so  as  to  invaginate  the  upper  into  the  lower  end,  to  the  point  of 
the  lower  limit  of  denudation,  then  pinning  it  there  by  piercing  transversely 
the  coats  of  the  distal  end  {h) ;  repeat  with  the  second  needle  the  same 
action  at  the  corresponding  point  of  the  opposite  side  (c).  The  portion 
opposite  the  mesenteric  attachment  is  treated  in  a  like  manner  with  the 
third  needle  (c).  The  needles  are  then  carried  through,  stitches  tied,  and 
permanent  fixation  is  established  {d).    The  exposed  end  of  the  bowel  is  then 


664. 


OPERATIVE  SURGERY. 


sewed  to  the  invagiuated  part  with  interrupted  or  continuous  sewing,  prefer- 
ably the  former,  as  less  liability  of  contraction  is  encountered.  This  method 
of  practice  is  well  conceived,  always  available,  can  be  quickly  applied,  and 
thus  far  the  use  has  been  followed  by  commendable  results. 

The  use  of  the  Murphy  button,  the  bone  bobbin,  Senn's  modification  of 
Jobert's  method  (page  624  et  seq.),  or  Maunsell's  method,  in  lieu  of  the 
stereotyped  end-to-end  union  by  sewing,  will,  no  doubt,  be  advantageous  in 
many  instances.  The  surgeon  who  makes  a  wise  selection  of  one  of  many 
resources  is  possibly  a  safer  custodian  of  human  life  than  one  who  is  wedded 
to  a  single  expedient,  even  though  it  be  of  his  own  creation. 


Fig.  877. — Circwlar  eiitei-on-li;ij)liy,  Harris's  method. 


The  Treatment  of  the  Mesentery. — Several  methods  of  management  of  the 
mesentery  are  practiced  :  1.  Its  division  close  to  the  bowel  (Figs.  870  and  878), 
the  folding  in  and  union  of  the  border  by  continuous  sewing,  and  final  clo- 
sure, by  sewing,  of  the  opening  left  after  uniting  the  intestinal  extremities 
(Fig.  879).  This  method  is  one  commonly  practiced.  It  has  been  sug- 
gested that  the  redundant  fold  be  turned  to  one  side  and  fastened  to  the 
overlapped  surface  by  a  few  silk  sutures  placed  at  the  borders  of  the  folded 
portion  {a).  2.  The  removal  of  a  triangular  piece  (Fig.  878,  b)  of  the  mes- 
entery along  with  the  portion  of  bowel  and  the  stitching  of  the  sides  of  the 
triangle  to  each  other  after  sewing  of  the  intestine  (Fig.  880).  Ordinarily, 
the  sides  of  the  triangle  should  not  exceed  the  length  of  the  base,  but  in 
operations  for  malignant  disease  of  the  intestine,  for  which  this  method  is 


orKKATlONS   ON    VlSClOKA   C'UNNKCTKl)    WITH    I'KUITUN J;L'M.     (;(;5 


ospcciiillv  adiipted,  iittcndecl  with  cnlurfrcment  of  the  mesenteric  glands,  the 
extent  of  the  outlines  of  the  triangle  niuy  be  g(jverned  by  the  extent  of  the 


b"ui.  S78. 


Kio,  87!). 


Fio.  878, 
and 
ilise; 

Fig.  879, 


, — Rosectiou  of  intestine,  rubber  bands  applied,     a.  Mesentery  ligatured,  divided 
ready  to  turn  tisidc  (l^ig.  879).     b.  V-shaped  piece  sometimes  removed  along  witli 
ised  area. 
, — Resection  of  intestine,  mesentery  turned  aside  and  borders  united. 


th 


disease.  This  method  leaves  a  smooth  mesenteric  surface,  equally  distrib- 
utes intestinal  movements,  and  is  artistic  in  its  finish.  Still,  it  is  thought 
to  interfere  with  the  vascular  supply  of  the  gut  more  than  tlie  preceding 
method.  3.  The  removal,  along 
with  the  mesenteric  border,  of  a 
strip  of  the  serous  coat  of  the  in- 
testine to  be  excised,  about  half 
an  inch  in  width  at  either  side 
of  the  mesenteric  attachment, 
and  closure  of  the  resulting  loop 
by  sewing  the  same  as  in  the  first 
instance.  This  method  is  more 
ingenious  than  practical  in  its 
bearings.  Mitchell  and  Hunter 
have  devised  an  admirable  stitch 
for  the  purpose  of  properly  appo- 
sing the  serous  membrane  to  the 
uncovered  part  of  the  bowel  at 
the  base  of  the  triangular  space  of  the  mesenteric  attachment  (Fig.  811), 
which  at  the  same  time  adds  much  indeed  to  securing  end-to-end  union  of 

the  intestinal  segments,  there- 
by   contributing    greatly   to 
?%RS:9w««''^    the  prevention  of  faecal  ex- 
travasation (Fig.  881). 

The  Comments. — Having 
completed  the  repair,  the 
parts  are  carefully  cleansed, 

w      001     ir-i  u  n       i   ii     *    '       *        t       i  retumcd    to   place,  and    the 

Fig.  881. — Mitchell  and   Hunters  suture  for  closure      .  ,  .      ,        ,       ^ 


Fig.  880. — Resection  of  intestine.     Union  of  bor- 
ders of  mesentery,  Ilalsted's  method. 


of  attached  border  of  mesentery. 


abdomen  is  closed.     In  some 


QQQ  OPERATIVE  SURGERY. 

instances,  however,  especially  those  in  which  for  any  reason  the  intestines 
are  overdisteuded  and  oppose  return  and  confinement  in  the  abdomen, 
their  contents  should  be  discharged  through  one  or  more  free  incisions 
made  at  proper  points  in  the  longitudinal  axis  of  the  gut  with  a  scalpel. 
These  incisions  can  be  easily  closed  by  intestinal  sewing.  McCosh  practices 
the  injection  of  a  solution  of  magnesium  sulphate  into  the  bowel,  before 
closure  of  the  incisions,  with  excellent  results.  Puncture  of  the  intestine 
with  a  trocar  is  much  less  etfective  and  quite  as  dangerous  as  the  free  inci- 
sion. The  spreading  over  the  intestines,  and  carrying  beneath  the  borders 
of  the  wound  an  antiseptic  towel,  thereby  forming  an  extemporized  wall  for 
the  better  return  of  the  distended  intestines  to  the  abdominal  cavity,  is  a 
practical  measure  highly  commended  by  Murphy.  The  raising  upward  with 
traction  sutures  of  the  borders  of  the  abdominal  incision,  thereby  forming  a 
funnel-like  opening,  is  often  soon  rewarded  by  safe  return  of  the  distended 
bowels.  The  toilet,  drainage,  and  closure  of  the  abdominal  cavity  has  been 
considered  already  under  the  head  of  Abdominal  Section  (page  612  et  seq.). 

The  Precautions. — If  the  condition  of  the  patient  will  permit,  overdis- 
tention  of  the  intestine  from  any  cause  should  be  relieved  through  an  incision 
into  the  injured  or  diseased  loop  before  resection  is  attempted,  to  avoid  the 
greater  chances  of  infection  incident  to  the  presence  of  the  distention  during 
repair,  and  also  to  secure  the  manipulative  advantage  of  its  absence  at  this 
time.  The  thorough  elimination  of  the  contents  of  a  distended  intestine  by 
means  of  free  irrigation  of  the  cavity  of  the  bowel  with  the  hot  saline  solu- 
tion is  to  be  commended  when  practicable.  Punctures  made  for  the  purpose 
of  eliminating  the  gas  from  an  overdisteuded  intestine  should  be  promptly 
closed  with  a  suture — in  fact,  it  is  wise  that  the  suture  intended  for  this 
purpose  be  laid  and  pushed  aside  before  the  puncture  is  made,  otherwise  the 
paralyzed  and  overdisteuded  state  of  the  bowel  wall  will  permit  of  precipitate 
escape  of  the  contents.  While  the  stereotyped  abdominal  incisions  usually 
meet  the  demands  of  a  case,  still,  it  is  important  to  remember  that  their 
extent  and  direction  should  conform  to  the  demands  of  close  inspection, 
prompt  manipulation,  and  thorough  elimination  of  infecting  agents  from  the 
abdominal  cavity.  Flushing  of  the  cavity  for  removal  of  blood  clots,  intes- 
tinal contents,  etc.,  is  commendable,  except  in  the  presence  of  established  in- 
fection (page  612),  then  flushing  is  likely  to  cause  diffusion  instead  of  elimi- 
nation of  infecting  agents.  In  any  event,  in  established  localized  infection, 
thorough  wiping  away  of  this  infection  should  precede  general  flushing. 

The  Residts. — The  modern  methods  of  procedure  in  gunshot  wounds  of 
the  abdomen  result  in  about  thirty  per  cent  of  recoveries,  as  compared  with 
ninety-five  per  cent  of  deaths  following  the  old  non-operative,  expectant 
method  of  treatment.  Twenty  per  cent  greater  rate  of  recovery  attends 
operations  made  during  the  first  five  hours  of  the  injury  than  in  those  made 
from  five  to  fifteen  hours  later.  The  results  of  intestinal  resection  for 
chronic  causes — those  not  attended  with  the  acute  peritoneal  infection  that 
so  often  characterizes  gunshot  wounds — are  better  than  for  gunshot  wounds 
alone,  and  may  yet  be  much  improved  by  earlier  diagnosis  and  prompter  opera- 
tive effort. 


(U'KUA'l'loNS   ON    VISCKUA   CONNKCTKI)    WITH    rKKlToX JXM.     «;<J7 

Gunshot  Wounds  of  th«  Duodenum.— Owin^'  to  tlie  iiitiiiiati'  ivhitions  to 
tlie  (luudfimiii  of  tlic  stoiiiacli,  |iaiici'c;is,  liver,  etc;.,  wounds  of  this  Ijowel  jire 
often  eonipliciited  with  iiijuiv  of  the  contiguous  viscera,  iind  therefore  uro 
correspondingly  dangerous.  W'ountls  of  the  duodenum  idtMie  are  not  .so 
critical  as  those  of  the  smaller  intestines,  since  only  llu;  upper  two  or  three 
inches  of  this  portion  of  the  bowel  are  intraperitoneal,  the  lower  two  thirds 
heing  covered  only  in  front  by  this  membrane.  AN'ounds  of  the  upper  part 
of  the  duodenum  arc  treated  like  those  of  other  intestines  similarly  a.ssociated 
with  pcrit()n;\3um.  A  wound  of  the  surface  uncovered  with  peritona-um,  as 
at  the  lower  two  thirds  of  the  gut,  should  be  closed  with  great  care,  scruj)U- 
lous  cleanliness,  and  re-enforced,  if  possible,  by  the  utilization  of  adjacent 
serous  covering  so  as  to  bring  serous  surfaces  in  contact  the  same  as  elsewhere 
in  intestinal  sewing.  Wounds  of  the  posterior  surface  of  the  lower  two  thirds 
of  the  duodenum  are  obviously  retroperitoneal  in  character,  and  therefore 
less  immediately  dangerous  than  when  communicating  directly  with  the 
peritoneal  cavity.  However,  repair  here  is  dilHcult  on  account  of  the  absence 
of  serous  surfaces ;  on  the  other  hand,  infection  is  greatly  hindered  for 
this  reason,  and  drainage  can  be  established  posteriorly  without  involvement 
of  the  serous  cavity  in  front,  if  necessary.  Unless  painstaking  care  be  exer- 
cised, {icnotratiiig  wounds  of  non-sorous  surfaces  will  escape  notice. 

Gunshot  Wounds  of  the  Large  Intestine. — Wounds  of  the  large  intestine 
are  less  frequent  and  fatal  than  are  those  of  the  small.  Wounds  of  the 
transverse  colon  are  more  fatal  than  those  of  the  ascending  and  descending 
portions,  because  of  its  greater  peritoneal  environment.  Wounds  of  the 
large  intestine  can  be  divided  practically  into  those  involving  the  serous  and 
those  involving  the  non-serous  surfaces  of  the  gut.  The  former  are  closed 
the  same  as  in  the  small  intestine ;  the  latter  in  the  careful  manner  that 
characterizes  the  sew'ing  of  non-serous  surfaces  of  other  parts  of  the  intesti- 
nal canal  (page  G53).  The  introduction  into  the  bowel  of  ordinary  air  by 
means  of  an  old-fashioned  bellows,  or  by  blowing,  even,  through  a  rubber  tube 
with  one  end  in  the  rectum,  can  be  employed  for  detection  of  obscure  wounds 
of  the  colon  in  lieu  of  insufflation  with  hydrogen  gas.  In  uncomplicated 
wounds  of  the  large  intestine  an  incision  in  the  median  line  is  usually  not 
necessary.  A  vertical  one  at  the  linea  semilunaris,  supplemented  when 
necessary  by  another  carried  outward  and  downward  tow\ard  the  S])ine,  affords 
ample  opportunity  for  examination  and  repair. 

Tlie  IxesnUs. — The  rate  of  recovery  after  operation  for  gunshot  wounds 
of  the  large  intestine  exceeds  that  of  the  small  by  three  or  four  per  cent. 

The  after-treatment  in  gunshot  wounds  is  not  especially  dissimilar  from 
that  for  other  grave  intestinal  operations.  The  ice-water  coil  can  be  applied 
to  the  abdomen  with  advantage  in  these  cases. 

Stab  Wounds  of  the  Abdomen. — In  stab  wounds  of  the  abdomen  one  of 
the  important  duties  is  to  determine  if  the  peritoneal  cavity  has  been  entered, 
which  is  accomplished  in  the  same  manner  as  in  gunshot  wounds.  Not 
infrequently  the  escape  through  the  wound  of  omentum  or  intestine  settles 
the  fact  at  once.  In  prospectively  estimating  the  extent  of  the  injury,  the 
nature  and  characteristics  of  the  penetrating  agent,  together  with  the  direc- 


QQQ  OPERATIVE   SURGERY. 

tion  and  force  of  the  blow,  must  be  determined  when  possible.  The  ascer- 
tainment of  these  facts  need  not  take  additional  time,  since  it  can  be  rapidly 
gained  during  the  preparatory  steps  for  the  operation,  which  steps  are  fre- 
quently made  the  more  comprehensive  by  reason  of  the  knowledge  thus 
gained.  The  primary  incision  is  commonly  made  at  the  seat  of  the  injury 
down  to  the  point  of  penetration.  All  haemorrhage  is  arrested,  the  abdo- 
men entered,  retraction  sutures  are  introduced,  and  the  borders  of  the  wound 
drawn  apart  with  as  little  disturbance  of  the  underlying  structures  as  possi- 
ble ;  the  omentum,  intestines,  and  mesentery  respectively  are  carefully  exam- 
ined, bleeding  points  caught,  and  wounds  closed  temporarily,  as  soon  as  found  ; 
blood,  infecting  agents,  and  foreign  bodies  are  carefully  wiped  away,  aided  by 
gentle  flushing  with  a  hot  saline  solution,  in  the  manner  already  described  in 
the  treatment  of  gunshot  wounds  of  the  abdomen.  .Severe  hemorrhage  is 
arrested  by  direct  pressure  with  sponges,  or  digital  pressure  on  the  aorta ;  the 
bleeding  points  are  caught  and  tied  with  silk.  Wounds  of  other  viscera  are 
looked  for,  if  contiguity  of  the  injury  or  other  circumstances  of  the  case  sug- 
gest the  possibility  of  such  a  complication.  In  fact,  but  few  practical  dif- 
ferences arise  in  the  treatment  of  gunshot  and  stab  wounds  of  the  abdomen. 
The  methods  of  repair  are  the  same  in  each,  but  of  the  simpler  types  in  the 
latter,  owing  to  the  simpler  nature  of  the  injury.  Punctured  wounds  of  the 
mesenteric  borders  of  the  intestine  are  united  tlie  same  as  those  of  the 
convex  surface,  unless  they  be  ragged ;  then  the  treatment  for  gunshot 
wounds  at  this  situation  is  practiced.  The  antisejjtic  care  during  the  opera- 
tion is  in  all  respects  similar  to  that  for  gunsliot  wounds. 

The  Comments. — A  prompt  examination  to  determine  the  presence  of 
peritoneal  penetration  should  be  made,  for  no  harm  can  follow  if  penetration 
have  not  taken  place,  and  much  good  may  come  with  the  knowledge  of  its 
occurrence.  The  escape  from  injury  of  the  intestines  in  stab  wounds  of 
the  abdominal  cavity  is,  indeed,  often  marvelous.  This  good  fortune  is  due 
almost  entirely  to  the  comparative  slowness  of  the  entry  of  the  penetrating 
agent,  and  its  dullness,  and  also  to  the  mobility  of  the  intestine,  especially 
when  empty.  The  wounds  inflicted  with  broad-bladed  or  double-edged 
weapons  are  especially  dangerous,  since  the  cut  in  the  intestine  is  large, 
and  the  escape  of  intestinal  contents  and  the  loss  of  blood  are  proportion- 
ately great.  Profuse  and  persistent  bleeding  often  attends  such  wounds  as 
these,  and  the  efforts  to  arrest  hsemorrhage  should  be  conducted  carefully 
to  avoid  unnecessary  spreading  of  effused  intestinal  contents. 

The  Results. — The  percentage  of  recoveries  is  estimated  differently  by 
different  authors;  from  13  (Dalton)  to  39.2-i  (Morton). 

Contused  Wounds  of  the  Abdomen. — Contused  wounds  of  the  abdomen 
are  often  complicated  with  contusions  and  lacerations  of  the  intestine. 
The  jejunum  suffers  most  frequently,  because  of  its  relations  to  the  spinal 
column  and  its  comparative  immobility.  The  ileum  is  next  in  order  of  fre- 
quency. The  duodenum  suffers  comparatively  often  when  its  brevity  and 
retired  position  are  considered.  However,  its  fixity  and  relation  to  the  spine 
predispose  greatly  to  injury.  The  colon  as  a  whole  is  well  protected  be- 
cause of  its   comparatively  secluded  position.     The  ruptures  vary  in  num- 


oi'KUA'rioNs  ()\  viscKKA  CON N KcTKD  wi'i'ii   i'i:ki'I'()nm:i:.m.    <;«;o 

ber  ami  extent.  In  ninety  per  cent  of  the  cases  they  are  sin<^le;  in  twenty 
per  cent  tliey  involve  almost,  and  occasionally  the  entire  width  of  the  bowel 
(Curtis),  the  usual  dimension  being  about  an  inch  in  length,  therefore  faecal 
extravasation  is  aconnnon  result.  Laceration  or  contusion  of  the  mesentery 
is  u  formiilable  complication,  as  it  hap]>ens  in  about  sixteen  ])er  (;ent  of 
tlie  cases,  and  eighty  percent  of  these  die  from  licemorrhage.  Inasmucli  as 
the  majority  of  {)aiients  tlie  in  forty-eight  hours  after  the  time  of  the  injury 
promjit  oj)crative  interference  is  denumded.  After  shock  has  subsided  and 
thorough  ase{>tic  preparation  for  operation  is  secured,  a  median  incision  four 
inches  in  length  is  made,  retraction  sutures  are  introduced,  and  the  borders 
of  the  incision  drawn  apart  sutticiently  to  permit  of  the  inspection  of  the 
exposed  abdominal  contents.  If  needful,  this  incision  can  be  eidarged  up- 
ward  or  downward  sutUciently  to  allow  of  a  com})leter  scrutiny,  (ias,  intes- 
tinal contents,  and  blood  may  be  noted  in  the  field  of  observation.  If  haem- 
orrhage be  proiu5unced,  the  bleeding  ])oints  must  be  sought  for  and  closed 
at  once,  and  all  intestiiud  openings  temporarily  closed  with  clamps  as  they 
appear  during  the  search.  Digital  compression  of  the  aorta  and  direct 
sponge  pressure  of  the  bleeding  field  should  be  i)racticcd  if  necessary,  to 
arrest  the  outpour  of  blood.  Finding  the  location  of  the  bleeding  site  will 
often  be  facilitated  by  removal  of  the  intestines  from  the  abdominal  cavity, 
in  which  case  they  should  be  surrounded  by  rubber  tissue  and  supplemented 
by  aseptic  gauze  saturated  with  the  hot  saline  solution,  and  kept  thus  until 
returned  to  their  proper  place.  Infecting  agents  are  wiped  away  with  soft, 
moist,  hot  aseptic  sponges,  or  washed  out  with  a  saline  solution,  the  use  of 
which  often  stimulates  the  flagging  forces  of  the  patient,  and  enables  the 
surgeon  the  better  to  accomjilish  his  purposes.  If  contamination  of  the 
peritonttum  have  happened,  rapid  and  copious  flushing  and  cleansing  of  the 
peritoneal  cavity  and  the  intestines  with  a  hot  saline  solution  should  be 
practiced  before  their  return.  This  course  hastens  the  final  toilet  of  the 
cavity,  makes  it  the  more  thorough,  and  also  balances,  in  part,  at  least,  by 
stimulation  the  ill  effects  caused  by  the  eventration.  However,  repair  of 
the  defects  during  eventration  should  be  avoided  when  practicable,  as  this 
course  commonly  increases  the  gravity  of  the  case.  After  the  return  of  the 
intestines,  the  repair  of  lacerated  and  contused  wounds  of  the  convex  bor- 
der of  the  bowel  is  made  by  simple  inversion,  or  limited  excision  with  or 
without  "  elbowing "  (Fig.  86G)  as  the  extent  of  the  injury  may  require. 
Wounds  of  the  mesenteric  border  of  the  intestine  and  of  the  mesentery 
itself,  that  compromise  the  arterial  supply  of  the  gut,  are  followed  by  gan- 
grene, and  therefore  enterectomy  should  be  practiced  according  to  the  prin- 
ciples and  after  the  manner  employed  in  gunshot  wounds.  It  is  fi-equently 
necessary  to  abbreviate  remedial  effort  by  the  substitution  of  a  fiscal  fistula 
(enterostomy)  for  other  methods  of  procedure,  in  order  to  avoid  imminent 
danger  of  death  of  the  patient,  applying  the  final  remedy  later.  However, 
if  the  duodenum  or  the  upper  part  of  the  jejunum  be  involved,  the  practice 
of  enterostomy  is  soon  followed  by  starvation  and  death,  hence  the  defect 
should  be  promptly  remedied.  Therefore,  the  ileum  and  lower  part  of  the 
jejunum  are  the  parts  best  adapted  for  the  establishment  of  a  faecal  fistula. 


670  OPERATIVE   SURGERY. 

After  replacement  of  the  intestines,  the  necessary  measures  of  repair  are 
performed  with  the  aseptic  technique  heretofore  advised  for  the  purpose 
(page  653).  The  final  peritoneal  toilet,  drainage,  and  closure  of  the  abdo- 
men diifer  in  no  essential  respects  from  that  before  described  (page  012). 
Contused  points  of  intestine  attended  with  extravasation  within  the  tissue 
of  the  gut  should  be  turned  in  when  practicable,  and  the  borders  united  by 
sewing ;  the  borders  of  gaps  in  the  serous  covering  should  be  drawn  to- 
gether by  fine  silk  sutures. 

The  Results. — The  results  are  doubtful  at  the  best,  and  unfavorable  with- 
out early  action,  and  even  then  it  is  sometimes  wuser  to  make  a  temporary 
fistula  low  down  than  attempt  the  performance  of  a  radical  procedure. 

In  95  cases  the  mortality  from  operation  was  47  per  cent.  In  those  for 
horse-kick  alone  about  70  per  cent.  In  54  cases,  those  operated  on  before 
the  twentieth  hour,  80  per  cent  recovered  ;  after  this  time,  but  26  per  cent 
were  successful.  The  average  duration  of  operative  interference  was  an 
hour  in  the  successful  cases,  and  an  hour  and  twenty-five  minutes  in  the  un- 
successful. An  occasional  death  from  errors  in  technique  happened.  Cases 
of  injury  of  other  structures  than  the  intestines  and  their  associated  ves- 
sels are  excluded  from  this  list.  Temporary  enterostomy  was  practiced  in 
four  cases,  three  of  which  recovered. 

Abdominal  Section  in  Intestinal  Obstruction. — It  is  unusual,  indeed,  that 
the  services  of  a  surgeon  are  called  for  in  these  cases  in  time  to  afford  a 
fair  measure  of  success  to  the  patient.  The  uncertainty  in  diagnosis  and  the 
tendency  to  procrastination  rob  the  patient  too  often  of  the  benefits  of  sur- 
gical resources.  The  potent  influences  of  pain,  vomiting,  loss  of  sleep,  lack 
of  nutrition,  and  the  septic  effects  of  intestinal  accumulation  and  distention, 
are  usually  indelibly  stamped  on  the  features  and  vital  forces  of  the  patient 
at  the  time  the  surgeon  is  called.  Since  it  is  the  duty  of  the  surgeon  to  save 
life  irrespective  of  the  completeness  of  a  surgical  procedure,  frequently  he 
must  decide  between  the  adoption  of  temporary  enterostomy,  with  possible 
recovery,  and  completed  details  with  probable  death. 

Enterostomy. — Enterostomy  consists  in  the  making  of  an  opening  into 
the  small  intestine  and  the  temporary  or  permanent  attachment  of  its  bor- 
ders to  those  of  a  corresponding  opening  in  the  abdominal  wall,  for  the  pur- 
pose of  relieving  the  intestinal  distention  due  to  obstructionor  for  the  nour- 
ishment of  the  patient.  Enterostomy  is  usually  performed  at  the  right 
side,  but  it  may  be  done  at  the  median  line  or  the  left  side.  It  is  established 
in  the  median  line  when  it  is  found  to  be  impracticable  to  overcome  the  diffi- 
culty in  the  intestine  for  which  the  incision  was  made  and  when  to  estab- 
lish the  opening  elsewhere  would  be  inexpedient.  The  opening  under  these 
circumstances  becomes  an  artificial  anus. 

Kocher's  Method  {Fcecal  Fisinia). — Make  an  incision  at  the  outer  side  of 
the  epigastric  artery  two  inches  and  a  half  in  length,  parallel  with  and  an 
inch  and  a  half  above  Poupart's  ligament,  down  upon  the  peritonaeum. 
Arrest  haemorrhage  and  make  an  opening  in  the  peritoneum  an  inch  and  a 
half  in  length  ;  draw  carefully  into  the  opening  the  presenting  loop  of  dis- 
tended intestine  sufficiently  to  allow  only  the  convex  border  of  the  gut  to 


()I'i:i:a'I'I()Ns  on  visckua  connec'I'ki)  with  rHurnjNMa'M.    «;7i 


j)roji'ct  al)<)Vi'  tliL'  sm-facc  of  llu-  alxlonicii ;  piis.s  u  .^ilks\urni-<fiit  suture  at 
each  ciul  of  the  wound  thi(ju<;h  all  of  ihi-  tissues  at  u  little  distance  from  tlie 
borders,  iMeUidiii<f  the  serous  eoverin*,'  of  the  <,Mit,  thi.s  fixing  tiie  looj)  of 
intestine  and  shortening  tiie  })riinary  incision.  Sutures  nuiy  be  passed  simi- 
larly at  either  side  of  the  wound,  if  advisable.  Stitch  the  wall  of  the  bowel 
to  thedivided  i)eritonu'um  with  a  continuous  silk  suture  (Fig.  88:3);  supple- 
ment this  row  with  a  su])erticial  one  of  catgut,  uniting  the  integument  with 
the  serous  and  muscular  walls  of  the  bowel,  carefully  avoiding  penetration 
of  the  gut;  smear  the  wound  freely  with  iodoformized  vaseline  to  prevent 
the  contact  of  intestinal  contents  with  the  raw  surfaces;  puncture  the  pro- 
truding loo])  at  tiie  convex  border  with  the  point  of  a  scalpel,  and  direct 
the  escaping  substances  aside  with  rubber 
tissue,  or  oiled  silk,  as  fast  as  they  escape. 
No  effort  should  be  made  to  hasten  the  dis- 
charge, uor  should  the  intestinal  canal  be 
flushed.  After  the  vigor  of  the  flow  has 
ceased,  wipe  the  integument  dry,  smear  it 
with  vaseline,  cover  the  wound  with  an  abun- 
dance of  absorbent  cotton  or  with  oakum, 
which  dressing  confine  in  place  loosely  and 
change  when  soiled.  If  the  case  be  very 
urgent,  the  supplementary  row  of  sutures 
can  be  omitted.  If  delay  be  permissible, 
the  intestine  need  not  be  opened  so  soon, 
two  or  three  days  being  granted  to  first  secure 
firm  adhesion  of  the  gut  to  the  borders  of  the 
wound.  The  median  incision  of  an  explora- 
tory operation  can  be  utilized  in  forming  an 
artificial  anus,  in  case  it  be  necessary  to  desist 
from  further  radical  procedure.  This  incision  offers  the  advantages  of  a 
definite  diagnosis,  and  the  location  of  the  fa?cal  fistula  close  to  the  point 
of  obstruction,  which  are  important  desiderata  if  no  further  efforts  at  relief 
are  contemplated. 

21ie  Precautions. — The  division  of  the  epigastric  artery  will  be  an  em- 
barrassing complication.  However,  as  it  runs  upward  and  inward  from 
behind  the  middle  of  Poupart's  ligament,  it  can  be  easily  avoided  by  cutting 
outside  of  the  latter  point.  Care  should  be  taken  to  obviate  a  twist  in  the 
presenting  loop  of  intestine  for  self-evident  reasons.  It  is  likewise  apparent 
that  the  opening  of  a  collapsed  intestine  will  afford  no  relief.  Scrupulous 
attention  should  be  given  to  the  condition  of  the  patient  during  operation  by 
one  assigned  for  that  purpose,  otherwise  an  unexpected  sudden  demise  of  the 
patient  will  deepen  the  responsibility  for  the  case.  If  the  intestine  be  much 
distended  the  walls  may  be  correspondingly  thinned,  and  therefore  readily 
punctured  in  sewing,  causing  infection  of  the  deep  tissues  of  the  wound  and 
perhaps  of  the  peritoneal  cavity  itself. 

The  Remarks. — The  opening  in  the  gut  should  be  as  small  as  practicable, 
to  avoid  undue  prolapse  of  the  mucous  lining  of  the  bowel,  and  to  limit  the 


Fig.  882. — Enterostomy,  Kocher's 
method,  a.  Parietal  perito- 
nteum.  h.  Aponeurosis  of  ex- 
ternal oblique  ni.  c.  Transver- 
salis  fascia,     d.  Intestine. 


672 


operativp:  surgery. 


area  of  subsequent  repair.  The  length  of  the  primary  incision  will  be  regu- 
lated principally  by  the  thickness  of  the  abdominal  walls.  If  the  element  of 
time  be  unimportant,  the  borders  of  the  divided  peritonaeum  can  be  first 
stitched  to  those  of  the  integument,  thus  lining  the  opening  with  serous 
membrane,  thereby  providing  a  firmer  and  securer  union  between  the  intes- 
tine and  the  borders  of  the  opening. 

The  Results. — Xot  infrequently  the  establishment  of  a  faecal  fistula  cures 
entirely  the  original  infliction,  and  later  the  faeces  flow  uninterruptedly 
through  the  normal  channel.  The  following  statistics  compiled  by  Curtis, 
bearing  on  the  results  of  enterostomy  in  acute  intestinal  obstruction,  empha- 
size the  importance  of  the  procedure  in  no  uncertain  terms.  In  sixty-two 
cases  46  were  relieved,  6  unrelieved,  and  the  outcome  not  stated  in  10 ;  51.7 
per  cent  recovered,  and  in  60  per  cent  of  the  recoveries  the  f«cai  flow  resumed 
the  natural  channel.  Forty-eight  per  cent  died.  According  to  Curtis,  the 
rate  of  mortality  of  abdominal  section  in  this  class  of  cases  is  twenty  per  cent 
greater  than  that  of  enterostomy,  and  the  benefits  of  the  former  do  not  com- 
pensate for  greater  death  rate.  Some  patients  who  are  unable  to  endure 
enterostomy,  which  can  readily  be  performed  under  cocain  ansesthesia,  can 
not  be  expected  to  survive  the  operation  of  abdominal  section.  Therefore,  a 
patient  rescued  at  the  outset  by  the  safer  plan  has  a  subsequent  opportunity 
of  cure  by  the  graver  metliod. 

The  Making  of  an  Artificial  Anus  (Kocher)  in  the  small  intestine  differs  in 
an  important  degree  from  the  establishment  of  a  ftecal  fistula  at  the  same  situ- 
ation.   The  former  is  a  permanent  affair  and  includes  the  entire  width  of  the 

intestine,  so  that  all  the  faecal  matter 
passes  through  the  opening.  It  may  be 
established  in  the  groin  or  in  the  me- 
dian line.  Up  to  the  time  of  incision 
of  the  peritonaeum  there  is  no  practical 
difference  in  the  technique  of  the  two 
operations.  The  peritoneal  opening  is 
made  smaller  in  artificial  anus,  the 
loop  of  intestine  is  drawn  completely 
out  of  the  wound,  and  the  proximal 
extremity  placed  uppermost  before  the 
loop  is  stitched  to  the  borders  of  the 
peritoneal  incision  with  the  continuous 
silk  suture  (Fig.  883).  The  proximal 
part  of  the  loop  is  given  the  most  room, 
and  is  so  arranged  as  to  press  on  the 
distal  part.  Sew  the  parts  and  smear  them  with  vaseline,  as  in  enterostomy ; 
open  the  intestine  sufficiently  to  cause  free  and  complete  escape  of  the  con- 
tents ;  cleanse  the  wound  and  remove  the  triangular  portion  indicated  in  the 
illustration.  The  after-attention  is  all  a  matter  of  cleanliness  and  nutrition. 
The  RemarTcs. — It  is  proper  to  recall  under  this  heading  the  fact  that  a 
permanent  establishment  of  the  intesti7ie  in  relation  to  the  external  wound 
requires  that  the  obstruction  be  low  down,  and  that  the  opening  be  made  as 


Fig.  883. — Enterostomy,  Kocher"s  method. 
a.  Parietal  peritonaeum,  b.  Abdomi- 
nal muscles,  c.  Integument,  d.  Di- 
verging lines  of  division. 


Ol'KUA'IMONS   ON    VISCKHA    CONNKCTIM)    WTI'll    I'KIMl*  »N  Mll'M.     r,73 


near  tu  it  as  possible,  limiitritidii  ami  even  starvadoii  will  eiisiur  if  an 
artiliciiil  anus  bo  lociited  too  near  tlio  stotniich.  if  time  will  permit,  tlie 
operation  eaii  bo  ilivitletl  into  steps,  tlie  linal  one — the  opening  of  tiieaniis — 
being  deferred  until  after  adhesions  have  taken  place.      If  the  loop  with- 


Tmommmmmmf' 


Fit!.  884. —  I'Ubuwiiig  ill  circular  ciilcrorrlia|iii} ,   .JciUiiici's  iiiclliod. 

drawn  be  distended  it  should  be  emptied  into  a  contiguous  loop  and  clamped 
to  prevent  return  of  the  contents,  thus  avoiding  the  danger  of  penetration 
of  the  gut  in  sewing,  due  to  the  thinning  of  the  wall  dependent  on  over- 
distention.  The  abdominal-wall  sutures  close  to  the  protruding  parts  sliould 
be  clumped  until  these  parts  are  properly  adjusted  and  then  tied.  The  intes- 
tine may  be  fixed  in  place  in  this  instance  with  a  glass  rod  (Fig.  890,  ^•),  or 
by  a  similar  agent,  the  same  as  in  colostomy,  or  sutures  only  may  be  employed 
for  the  purpose.  The  smaller  the  protrusion  is,  consistent  with  utility,  the 
less  is  the  danger  from  contamination  and  of  annoyance  from  friction.  Be- 
fore opening  the  gut  it  is  often  expedient  to  introduce  at  either  side  of  the 
proposed  site  of  entrance  traction  sutures,  thus  securing  better  control  of  the 
part  during  evacuation.  The  trocar  and  cannula  may  be  employed,  or  the 
glass  tubes  of  Paul  (Fig.  892),  the  same  as  in  colostomy, 

Enteroplasty. — Enteroplasty  is  an  operation  commonly  applied  to  the  sur- 
gical treatment  of  the  denser  tissues  of  the  intestines,  without  resection,  for 
the  purpose  of  repairing  defects 


in  the  caliber  of  the  gut  (Figs. 
8G3  and  865),  as  in  pyloro- 
plasty (page  995  et  seq.)  by  the 
various  methods  of  elbowing 
(Fig.  8G6),etc.  Jen n neJ cVoow^ 
the  intestine  in  performing  cir- 
cular enterorrhaphy  by  mak- 
ing oblique  section  of  the  ends 
(Fig.  884),  his  reason  therefor 
being  to  allow  a  larger  caliber 
at  the  seat  of  union  (Fig.  885), 
to  offset  the  subsequent  nar- 
rowing from  cicatricial  con- 
traction. The  dangers  from 
kinking  are  greater  in  this 
than  in  the  preceding  method 


Fig.  885. — Elbowing  in  circular  enterorrhaphy, 
borilers  united.  Jeannel's  method. 


674 


OPERATIVE   SURGERY. 


800) ;   and,  besides,  it  is  less  expeditious  and  in  nowise   the   better 


Chaput  elbows  the  intestine  by  uniting  the  transversely  severed  ends, 
followed  by  slitting  the  bowel  opposite  the  mesentery  for  an  inch  or  more, 
trimming  the  corners,  and  sewing  together  the  borders  (Fig.  880).  This 
method  has  no  practical  advantages  over  the  preceding.  Chaput's  method 
of  circular  enterorrhaphy  with  oblique  incision  without  elbowing,  is  accom- 
plished by  cutting  the  ends  transversely  in  the  long  axis,  so  as  to  form  an 


7^:^-F->r,^:fTTl  11' 


^''''/5,VMij#/i'--'i> 


Fig.   886.  —  Elbowing  by  circular   enterorrhaphy    and    longitudinal    flitting,   Chaput's 

method. 

equal  ellipse  at  opposite  sides  of  either  extremity  of  the  intestine  (Fig.  887). 
The  mesenteric  involvement  in  these  incisions  is  not  regarded  as  significant. 
The  union  of  the  ends  secures  a  long  oblique  line  of  coaptation  and  leaves 
the  intestine  straight.  We  are  disposed  to  extend  the  application  of  the 
term  enteroplasty,  for  the  sake  of  convenience,  at  least,  to  the  repair  of  serous 
surfaces  of  the  intestines  by  means  of  omental  grafting,  and  the  transference 
of  serous  membranes  by  sliding,  jumping,  etc.,  as  may  be  required  in  con- 
nection with  repair  of  a  wounded,  non-serous  intestinal  surface. 


%^Ks 


\(? 


Fig.  887.— Circular  enterorrhaphy,  obliiiue  section,  no  elbowing. 

Omental  Grafting  was  set  forth  by  Senn,  and  is  advised  for  the  repair  of 
the  peritoneal  defects  incident  to  the  union  of  serous  surfaces  by  sewing. 
Omental  grafting  is  practiced  in  the  following  manner:  Grafts  of  proper 
size  and  shape  to  meet  the  indication  are  cut  from  the  omentum  and  placed 
at  once  in  the  hot  saline  solution.  Slight  scarification  for  an  inch  or  so  at 
both  sides  of  the  part  to  be  repaired  is  quickly  practiced ;  take  the  graft 
from  the  solution,  place  it  between  two  layers  of  aseptic  gauze  to  remove 


Ul'KIiATlONS   ON    VISC'KKV   CONNECTED    Wiril    I'EKiToN.EUM.     «;75 

siipcrtliious  fluid,  phiee  it  carefully  in  position  over  the  serous  defect  lunl  fix 

it  there  with  a  few  line  nitgut  sutures  (Fig.  HHH).     In  the  course  of  u  few 

hours    the    graft     becomes    quite 

tirnily  adherent.     Omental    graft-     ^ 

iiig   is    advised    for  the  repair  of 

other  peritoneal  defects  than  those  ^     o^        / 

the    result   of    sewing,  to   obviate  j  w 

adhesion    of    injured    ser(»us    sur-  J^ 

faces.      Tiie  olgection   is  made  to     -  '   ,^  ■  ~~--- 

this    kind    of    grafting    that    the  7    ■ 

jriafts  contract  and  interfere  with  L 

the  outline  and  caliber  of  the  In-  r  w 

men  of  the  intestine.  F.u.HM8.-0„u...tal  graft  (0.^.).  Sena's  im-thod. 

Colostomy. — The  term  colos- 
tomy is  applied  to  the  establishment  of  an  artificial  anus  in  the  colon,  but 
for  the  sake  of  simplicity  it  should  include  also  the  caecum  and  sigmoid 
flexure.  The  object  of  the  operation  is  for  the  relief  of  obstruction  of  the 
large  intestine,  and  to  divert  the  faecal  current  from  contact  with  distal 
ulcerating  and  sinous  surfaces.  The  author  has  once  performed  colos- 
tomy for  the  relief  of  otherwise  inoperable  prolapse  of  the  rectum  with 
marked  ])alliative  results.  There  are  two  common  varieties  of  colostoiny, 
inguinal  and  lumbar,  the  former  being  intraperitoneal  and  the  latter  usually 
extraperitoneal.  Inguinal  colostomy  may  relate  to  the  csecum  or  sigmoid 
flexure  according  to  the  side  attacked.  Lumbar  colostomy  is  applicable  to 
either  side,  but  is  commonly  effected  at  the  left  (Fig.  889). 

Iliac  Colostomy  (Littre).— Formerly  the  lumbar  incision  was  more  com- 
monly employed  than  this  one,  but  now  it  is  rarely  done  except  in  those  cases 
in  which  malignant  involvement  or  binding  down  of  the  sigmoid  flexure  makes 
it  impracticable  to  open  or  reach  the  latter,  and  also  in  those  cases  attended 
with  great  distention  of  the  gut  and  other  manifestations  calling  for  prompt, 
imperative  action,  as  sometimes  happens.  An  artificial  anus  at  the  left  iliac 
fossa  is  more  conveniently  situated,  the  steps  of  the  operation  are  less  per- 
plexing, and  the  sequels  less  significant  than  in  lumbar  colostomy,  except  as 
to  the  danger  of  peritonitis,  and  even  this  is  insignificant  in  the  presence  of 
modern  aseptic  methods.  Moreover,  the  operation  is  easier  for  the  surgeon 
and  safer  for  the  patient,  so  far  as  antesthesia  is  concerned.  A  flaccid  colon 
in  a  fleshy  patient  renders  the  lumbar  operation  exceedingly  difficult.  How- 
ever, careless  technique  in  the  inguinal  operation  may  cause  fatal  peritonitis 
and  also  annoying  prolapse. 

The  Operation.— Phice  the  patient  on  the  back  with  the  limbs  extended; 
make  an  incision  two  inches  and  a  half  in  length  with  the  center  corre- 
sponding to  the  anterior  superior  spinous  process  of  the  ilium  at  a  point  an 
inch  and  a  half  inside  this  process  (Fig.  891)  in  the  course  of  the  fibers  of 
the  external  oblique  ;  separate  and  draw  apart  the  fibers  of  the  external 
oblique  and  in  turn  those  of  each  succeeding  muscle  as  soon  as  it  appears, 
until  the  transversalis  fascia  is  reached,  which,  along  with  the  peritoneum, 
is  divided  for  about  two  inches  in  the  line  of  separation  of  the  transversalis 
49 


676 


OPERATIVE   SURGERY. 


fibers ;  introduce  a  strong  retraction  suture  through  all  of  the  tissues  at  each 
side  of  the  wound,  in  order  to  draw  the  borders  of  the  wound  wide  apart  and 
prevent  the  stripping  up  of  the  peritoneum  incident  to  manipulation  ;  intro- 


FiG.  889. — Instruments  employed  in  colostomy,  etc. 

a.  Scalpels  and  bistouries,  b.  Scissors,  c.  Porci pressure.  d.  Needles  and  traction 
loops,  e.  Ligatures.  /.  Needle-holder,  g.  Sponge-holder.  h.  Blunt  retractors. 
I.  Blunt  hook.  k.  Glass  rod  and  iodoform  gauze  for  support  of  intestine.  I.  Thumb 
forceps.  Tenacula,  mouse-tooth  forceps,  sponges,  wijjefs,  large  rubber-tube  trocar 
and  cannula,  small  basin,  rubber  tissue,  and  an  abundance  of  gauze,  etc.,  should  be 
provided. 

duce  the  index  finger  into  the  abdominal  cavity  and  carefully  examine  the 
contiguous  parts  for  the  presence  of  disease  manifestations;  withdraw  the 
finger,  bringing  along  with  it  a  loop  of  the  sigmoid  flexure  ;  make  downward 


Ul'KKATlUNS   UN    VlSCKIvA   ('UNNEC'I'KD    \Vn'l[    I'KKlTUNvKLM.     (;77 


Frj 


890. —  lliuc  c-olostoiny,  rod  and  sutures 
placed  to  form  spur.  a.  Glass  rod.  b.  Sero- 
muscular sutures,  c.  Skin.  </.  Fascia'. 
e.  Muscles.    /.  Fascia'  and  peritona-um. 


traction  on  the  upper  limb  of  the  loop  and  thus  pull  tiic  intestine  from 
above,  returning  it  us  fust  below,  until  the  mesocohju  prevents  further 
escape;  pull  out  the  sifj^moid  loop  suiViciently  to  expo.se  tiie  attachment 
of  its  mesentery ;  o])en  the  mesentery  at  the  ])oint  of  attachment  near  to  the 
middle  of  the  loop  aiul  thrust  through  the  opening  a  sterilized  glass  (Fig. 
8!tO)  or  rubber  rod,  or  roll  of  iodoform  gauze,  of  sullicient  lengtli  to  rest 
readily  at  either  side  of  the  wound, 
on  the  surface  of  the  abdomen  ; 
lift  the  intestine  upward  a  little 
with  the  rod  or  gauze  and  unite 
the  portions  of  the  loop  immedi- 
ately above  and  below  it  with 
each  other  by  two  sutures  passed 
at  either  side  through  the  sero- 
muscular walls  of  the  intestine 
and  tied  so  as  to  form  a  proper 
spur  (Fig.  891) ;  unite  the  protru- 
sion to  the  borders  of  the  abdominal  opening  by  interrupted  silk  sutures 
passed  with  a  curved  needle  through  only  the  musculo-peritoneal  borders 
of  the  wound  and  the  sero-muscular  coats  of  the  intestine  respectively ; 
cut  the  ends  of  the  sutures  long,  treat  the  intestine  with  sterilized  vaseline 
and  the  remaining  portion  of  the  wound  with  iodoform  gauze.  Cover  the 
whole  wdth  aseptic  gauze  held  in  place  by  an  ordinary  binder.  At  tlie  end 
of  three  days,  union  of  the  surfaces  will  have  occurred,  when,  according  to 
the  demands  of  the  case,  one  of  two  courses  can  be  pursued,  the  establish- 
ment either  of  a  permanent  artificial  anus  or  of  a  temporary  faecal  fistula. 
If  an  artificial  anus  be  the  desideratum,  seize  the  loop  of  intestine  with 

mouse-toothed  forceps,  and  with  scissors 
remove  the  wall  of  the  bowel  to  within 
half  an  inch  of  the  line  of  stituring,  ar- 
resting the  bleeding  points  as  they  arise  ; 
divide  the  bowel  through  transversely  in 
the  line  of  the  rod,  permitting  the  lower 
segment  to  retract ;  remove  the  sutures 
first  applied  and  stitch  the  end  of  the 
upper  segment  to  the  integumentary 
borders  of  the  wound.  If  only  a  tem- 
porary faecal  fistula  is  desired,  make  a 
short,  longitudinal  incision  at  the  con- 
vex surface  of  the  loop,  remove  the  jiri- 
mary  sutures,  and  join  the  borders  of  the 
intestinal  incision  at  three  or  four  points 
with  the  integumentary  borders  of  the  wound.  The  rod  is  removed  in  a 
week  or  ten  days  and  the  sutures  taken  away.  The  bowel  then  falls  down- 
ward into  place,  retraction  obliterates  the  spur,  and  more  or  less  of  the 
faecal  flow  resumes  the  natural  channel,  and  thus  it  continues  until  cured 
bv  natural  or  artificial  means. 


Fiu.  891. — Tliac  coloMomy,  bowel  raised 
up  atid  supported  by  a  firm  roll  of 
iodoform  gauze  (Fig.  963). 


678  OPERATIVE   SURGERY. 

21ie  Remarhs. — Instead  of  the  glass  rod  or  iodoform  gauze  to  hold  the 
intestine  in  place,  the  mesocolon  can  be  sewed  to  the  borders  of  the  wound. 
After  closure  of  the  opening  of  the  distal  part  of  the  bowel,  Paul  advises  the 
introduction  into  the  proximal  part  of  a  glass  tube  an  inch  in  diameter  (Fig. 
892),  to  which  is  connected  a  rubber  tube  to  carry  away  the  faical  discharge. 
Later,  the  superfluous  extremity  of  the  bowel  is  cut  off.  The  stitching  of 
the  parietal  peritonaeum  to  the  integumentary  border 
of  the  wound,  to  secure  prompt  union  with  the  gut, 
is  practiced  infrequently  now,  because  the  repair  is  re- 
garded less  secure  than  that  from  tlie  contact  of  the 
cut  borders  of  the  wound  with  the  bowel.  Neverthe- 
less, if  the  bowel  be  fastened  as  directed,  the  prompter 
union  may  be  secured  without  special  danger  of  sub- 
sequent prolapse.  If  the  sigmoid  flexure  evade  detec- 
tion, the  introduction  of  water  or  air  into  the  rectum, 
Fig.  892.— Paul's  tubes  with  the  finger  at  the  brim  of  the  pelvis,  will  soon 
for  use  in  colostomy,   reveal  the  whereabouts  of  the  bowel,  and  if  it  pass 

a.  For  larofe  intestine.    .      j,  •.        •  i      j.i        -i.       j!  i.i  i-         i       ii 

b.  For  small  intestine,   ^o  the  opposite  Side  the  Site  01  the  operation  should 

be  changed  at  once. 

The  Precautions. — Pull  down  as  much  of  the  sigmoid  flexure  as  practi- 
cable before  uniting  it  with  the  wound,  to  limit  the  subsequent  prolapse  of 
mucous  membrane.  If,  as  sometimes  happens,  the  presenting  loop  be 
twisted  at  this  time,  the  direction  of  the  line  of  traction  will  be  reversed, 
with  obvious  results.  The  opening  in  the  distal  extremity  of  the  divided  gut 
should  not  be  permitted  to  close  when  frequent  cleansing  of  this  portion  of 
intestine  is  desirable,  as  in  connection  with  malignant  disease.  In  fact,  the 
patency  should  be  maintained  in  these  cases  by  the  introduction  through  the 
opening  of  a  large  rubber  tube  or  a  plug  of  gauze.  If  entrance  of  faecal 
matter  to  the  lower  segment  of  the  bowel  be  not  prevented  primarily  by  the 
inversion  and  closure  of  the  borders  of  the  opening  (Senn),  the  influence  of 
subsequent  cicatrization  may  close  it  with  or  without  the  aid  of  supplemen- 
tary procedure.  Much  has  been  said  from  time  to  time  regarding  the  prac- 
tice of  dividing  the  bowel  entirely,  closing  the  lower  end,  and  dropping  into 
the  peritoneal  cavity.  At  the  first  blush  this  course  seems  practicable,  since 
it  at  once  prevents  the  entrance  thereto  of  fa?cal  matter,  but  when  it  is  re- 
called that  a  long,  twisted  mesentery  may  again — as  often  before — cause  the 
upper  to  be  mistaken  for  the  lower  part — unless  the  latter  have  been  explored 
from  below — that  the  lower  may  contain  already  much  faecal  matter ;  that  divi- 
sion of  the  gut  increases  the  difficulty  of  operation,  and  exposes  to  greater  dan- 
ger of  infection  ;  and,  finally,  that  the  formation  of  a  pronounced  spur  will 
prevent  fgecal  flow  into  the  distant  part,  which  still  remains  patent  for  cleans- 
ing purposes,  it  will  be  seen  little  remains  to  be  said  in  support  of  the  practice. 

The  Sequels. — Faecal  incontinence  should  be  treated  with  compresses,  or 
even  a  hernial  truss;  excoriations,  with  vaseline,  oxide  of  zinc,  etc. ;  prolapse 
of  mucous  membrane,  by  excision  and  reunion  to  the  borders  of  the  wound. 

The  Results.— The  rate  of  mortality  from  the  operation  alone  is  about 
two  per  cent. 


<»IM:I{A'I'I<)NS   on    VlSCKIt.V    CONNKCrKI)    WITH    l'i;i{|'r<)NM;['M. 


OT'J 


Bodilie's  Method. — Tlie  steps  of  this  conuneiKhible  ])i-o(;o(liirc  iiec-d  not 
differ  in  any  essontiul  regiird  from  those  of  the  preceding  until  after  division 
of  the  peritonanini.  Tlui  divided  t)orders  of  this  nicniljriine  iire  tlicn  stitclied 
to  those  of  the  integiinieiit.  A  loop  of  intcstiiic  :il)out  twelve  inches  in 
length  is  diawii  out  through  the  oi)eniiig,  and  earefully  i)rotected  with 
gauze;  the  surfai-es  of  the  intestine  are  properly  apposed  and  held  in  place 
by  two  rows  of  eontiinious  silk  sutures,  six  inches  in  length,  ])lace(l  one  inch 
apart,  one  row  behind  the  other  in  front  of  the  loop  (Fig.  8IK3).  The  loop 
is  then  pressed  back  into  the  peritoneal  cavity  until  the  point  at  which  the 
opening  is  to  be  made  is  nearly  on  a  level  (a)  with  the  integument,  when,  if 
the  gut  is  to  be  opened  at  once,  it  is  joined  to  the  margin  of  the  abdominal 
wound  by  a  continuous  silk- suture  ;  if  not  until  twenty-four  hours  later,  cat- 
gut may  be  used  instead.  Any  important  structural  change  of  the  wall  of 
the  intestine  at  this  situation  should  be  made  to  appear  at  the  apex  of  the 
loop,  and  the  intestinal  surfaces  are  then  so  united  for  about  six  inches,  that 
thereafter  the  morbid  jn-ocess  can   be  removed,  leaving  the  spur  projjcrly 


Fig,  893. — Bodine's  opiTutioii  of  colostomy  by  lateral  apiiroximatlon,  with  final  restora- 
tion of  the  continuity  of  the  canal.  The  sewing  of  one  side  of  tlie  loop  is  shown, 
with  the  bowel  pushed  back  and  ready  for  stitching  to  the  abdominal  wound.  The 
lesion  remains  without,  and  the  dotted  line  (a)  indicates  where  it  is  to  be  cut  off. 


located.     If  the  fistula  is  to  be  permanent  the  mesenteric  attachment  may 
be  located  midway  between  the  two  rows  of  sutures. 

If  subsequent  repair  oi  the  intestine  be  contemplated,  the  approximation 
sutures  should  be  so  placed  that  one  row  will  be  close  to  and  parallel  with 


GSO 


OPERATIVE   SURGERY. 


the  meseuteric  attachment,  and  the  deepest  part  of  the  approximation  should 
be  fortified  by  interrupted  and  continuous  sutures  to  secure  that  part  against 
all  danger  of  leakage  after  division  of  the  septum. 

The  cure  of  a  f weal  fistula  established  by  this  method  of  practice  is  sin- 
gularly simj^le,  safe,  and  effective.  For  this  purpose  the  septum  is  divided 
in  the  median  line  with  Grant's  enterotorae  (Fig.  894),  or  with  ordinary 
sharp,  blunt-pointed  scissors,  carefully  guided  by  the  finger.  The  external 
opening  is  then  closed  in  the  usual  manner.  In  dividing  the  septum  care 
should  be  taken  not  to  injure  the  mesenteric  vessels  lying  near  its  border, 
nor  to  sever  the  lower  limits  of  the  approximation.      In   the  instance  of 


Fig.  894. — Bodine's  operation  of  colostomy,  showing  division  of  the  septum  with  Grant's 
enterotome  in  restoring  the  fa^-al  current.  In  permanent  colostomy  this  septum 
remains  as  a  rigid  and  efEective  spur. 


either  a  temporary  or  permanent  fistula,  delayed  opening  of  the  gut  can  be 
readily  accomplished  under  localized  cocain  anaesthesia. 

Cripps's  Method. — The  technique  of  Cripps's  method  differs  from  that  of 
the  preceding  in  some  important  respects.  Cripps  united  the  borders  of 
the  divided  peritonaeum  with  corresponding  borders  of  the  integument  with 
several  stitches  {J,  J),  thus  lining  the  opening  with  a  serous  surface.  The 
intestine  is  drawn  into  the  opening  by  means  of  traction  sutures  (a,  a)  passed 
through  the  anterior  fibrous  band  of  the  intestine  (Fig.  895),  and  it  is  then 
sewn  to  the  skin  and  peritonaeum  in  such  fashion  that  two  thirds  of  the  cir- 
cumference of  the  bowel  will  present  outside  the  sutures ;  the  sutures  at  the 
lower  border  are  passed  through  the  lower  longitudinal  band,  and  at  the  inner. 


Ol'KUA'rioNS   (>\    VISCEKA    CONNKCTKD    Willi    I'lllMTON^'^UM.     081 

tliruiigli  tlie  niiiscular  coats  of  the  iiitcstiiit'  near  to  tluf  incseutoric  attiichmeiit 
(Fig.  890).     In  the  later  cases  Oripps  made  the  inelsioii  higher,  nearly  on  a 


Fig.  895. — Iliuf  colostomy,  Cripps's  mot liod.     a,  a.  Traclioii  loop  passed  tlirough  fiijrons 
band,     h,  h.  Sero-cutaneous  sutures. 

level  with  the  umbilicus,  iu  order  that  the  lower  part  of  the  abdominal  wall, 
"where  the  pressure  is  the  greatest,"  may  be  spared  as  much  as  possible; 
also,  he  made  the  incision  into  the  abdomen  as  small  as  practicable  for  a 
similar  reason,  and  to  prevent  prolapse. 


--ii-i^>-!  > 


Fig.  896. — Iliae  eolostouiy,  Cripps's  method.     Intestine  sutured  in  place. 

TJie  After-treatment.  —  The  wound  is  dressed  lightly  with  iodoform 
gauze,  and  is  examined  thereafter  in  twenty-four  hours  to  note  if  proper 
union  be  maintained,  and  may  not  again  be  inspected  until  the  time  for 
opening  the  bowel  has  arrived. 

Re'cliis's  Method. — rjeclus  regards  the  preceding  method  as  unnecessarily 
complicated,  and  advises  the  employment  of  local  ana?sthesia  (cocain) 
and  a  short  vertical  incision  (two-inch)  located  between  the  anterior  supe- 
rior spine  and  the  umbilicus;  also,  pulling  the  colon  (sigmoid)  through 
the  opening  so  as  to  expose  the  mesenteric  attachment,  and  transfixing 
it  and  introducing  the  supporting  rod  out  of  line  with  the  vessels,  as  low- 
down  as  possible,  to  increase  the  prominence  of  the  anal  end  of  the  gut. 
Simple  aseptic  dressings  are  then  applied,  and  at  the  end  of  the  third  day 
the  bowel  is  opened  by  a  short  longitudinal  incision.  Any  distention  hap- 
pening before   this   time  can  be    relieved    by  the  passage  of  a  fine  trocar 


682  OPERATIVE  SURGERY. 

obliquely  into  the  gut.  The  supporting  rod  can  be  left  in  place  for  two  weeks. 
The  adhesion  of  the  serous  surface  of  the  bowel  to  the  tissues  of  the  wall  of  the 
wound  is  regarded  by  Eeclus  as  firmer  than  the  union  of  serous  surfaces  with 
each  other.  Hartmann  draws  through  a  four-inch  intermuscular  dissection 
— the  center  an  inch  inside  the  spine — the  sigmoid.  He  transfixes  the  mesen- 
tery with  gauze,  dresses  the  protrusion  with  it,  ami  in  forty-eight  hours  burns 
a  small  hole  with  cautery  through  the  anterior  longitudinal  band  at  the  upper 
limit  of  the  wound.     ResiiUs  excellent  in  all  respects ;  no  stitches  used. 

Iliac  colostomy,  right,  should  not  be  employed  except  as  a  temporary 
measure.  The  anatomical  obstacles  and  the  physiological  objections  to  it 
are  of  a  pronounced  character.  The  absence  or  brevity  of  the  mesocolon 
making  it  difficult  sometimes  to  properly  unite  the  colon  with  the  wound, 
and  the  fluidity  of  the  fsecal  contents  produce  frequent,  unexpected,  and 
irritating  movements,  which  cause  debility  and  distress,  each  of  which  em- 
phasizes strongly  the  unwisdom  of  the  practice  of  this  method.  The  tech- 
nique of  entry  to  the  abdomen  here  is  practiced  at  a  higher  point,  but  in 
other  respects  is  similar  to  that  of  the  left  side.  When  right  iliac  colostomy 
is  performed  a  fi.stulous  opening  is  desired,  since  it  meets  the  demands  of 
emergency  and  can  be  soon  supplanted  by  anastomosis  of  the  ileum  with  the 
descending  colon  or  sigmoid  flexure. 

If  the  abdominal  incision  be  located  comparatively  as  in  left  iliac  colos- 
tomy, the  cfficum  will  appear  at  the  wound,  and  can  be  easily  joined  with  the 
borders  by  sewing.  Only  fajcal  fistula  can  be  established  at  this  point.  The 
physiological  objections  urged  against  opening  the  colon  at  the  right  side 
apply  with  a  still  greater  force  to  opening  the  cajcum. 

The  Comments. — It  may  be  necessary  to  open  temporarily  the  caecum  to 
prevent  its  rupture  because  of  distention  due  to  obstruction  of  the  distal  part 
of  the  bowel.  If  right  colostomy  be  attempted  and  failure  attend  the  caecum 
may  then  be  opened. 

Colostomy  of  the  transverse  colon  is  rarely  performed,  and  then  only 
when,  for  any  good  reason,  the  portion  of  the  bowel  beyond  is  unfitted  for 
operation  at  the  usual  site. 

Lumbar  Colostomy,  Left  (Amussat). — Left  lumbar  colostomy  was  for- 
merly the  accepted  plan  of  entrance  to  the  colon.  But  the  beneficent  influ- 
ence of  asepsis  in  the  prevention  of  peritoneal  inflammation,  together  with 
the  facts  that  the  posterior  incision  produced  greater  traumatism  and  exposed 
broader  surfaces  to  infection,  while  it  offered  no  good  opportunity  for  intra- 
abdominal exploration,  and  placed  the  artificial  opening  inconveniently, 
prompted  the  substitution  of  the  anterior  for  the  posterior  method  in  the 
majority  of  instances. 

The  Linear  Guide  to  the  Ojjeration  (Fig.  897). — Draw  a  direct  line 
between  the  anterior  and  posterior  superior  spinous  processes  of  the  ilium ; 
draw  a  second  one  perpendicular  to  this,  one  inch  posterior  to  its  center,  to 
mark  the  line  of  the  colon.  Draw  a  third  line  with  the  center  correspond- 
ing to  the  perpendicular  one  obliquely  downward  and  outward  four  inches 
in  length,  parallel  with  the  lower  border  of  the  last  rib  and  midway  between 
it  and  the  crest  of  the  ilium,  to  mark  the  course  of  the  primary  incision. 


Ol'I'MiATlONS   ON    VIS('KI{A    CONNKC'IKD    WITH    I'KKI'HjNvKUM.     0«3 


Fi(i.  897. — Iliac  colosloiiiy.     a.  Colon,     b.  Veilical  line 
indicating  colon,     c.  Line  of  incision  in  operation. 


7'/ie  MiiscuUir  liuidrs  to  the  Oprrittion. — The  siiperficiiil  niiiscular  guide 
is  tlie  outer  border  of  the  erector  spiiui'  iimscle;  the  deep  one  the  outer  bor- 
der and  anterior  surface  of  the  (piadratus  luinboruni  muscle. 

Tlie  Anatoinical  Points. — A  mesocolon  is  })reseut  at  this  situation  in 
thirty-six  per  cent  of  the  cases  ('rrcves).  If  it  be  not  present,  tlie  posterior 
and  a  greater  or  lesser  ])()r- 
tion  of  the  lateral  surfaces 
of  the  colon  are  uncovered 
with  peritonu'uni.  If  the 
gut  be  collapsed,  it  retreats 
toward  the  median  line  be- 
hind tlie  quadratus  luin- 
boruni, followed  by  the 
peritoneal  covering,  and 
therefore  exposes  the  peri- 
tonaeum to  a  greater  dan- 
ger of  injury  than  when  dis- 
tended, since  it  then  })resses 
the  peritonteum  outward, 
and  itself  extends  beyond 
the  border  of  the  quadratus  lumborum.  The  intestinal  surface  not  covered 
with  peritonaeum  is  hidden  by  subserous  fatty  tissue  abundant  in  corpulent 
subjects.  The  colon  is  separated  at  this  situation  from  the  kidney,  cms  of 
the  diaphragm,  and  anterior  surface  of  the  quadratus  lumborum  respectively 
by  fatty  tissue.  The  small  intestines  when  present  here  extend  to  the  outer 
side  of  the  colon.  The  kidney  is  placed  behind  the  colon,  and  its  upper 
end  can  be  easily  determined  if  the  finger  be  directed  upward  through  the 
wound.  The  ilio-hypogastric  and  ilio-inguinal  nerves  pass  obliquely  out- 
ward in  front  of  the  quadratus  lumborum  muscle,  along  with  the  abdominal 
branches  of  the  lumbar  vessels. 

The  colon  is  rerognized  by  its  greenish  color,  scybalous  contents,  and  its 
thin  longitudinal  bands:  one  anteriorly,  one  posteriorly  at  the  point  of  at- 
tachment of  the  mesocolon  when  present,  and  one  internally.  Although 
the  colon  is  not  quiet  during  respiration,  yet  it  does  not  move  upward  and 
downward,  as  the  small  intestines  are  sure  to  do  at  this  time.  ]\Ioreover,  the 
colon  is  so  fixed  as  to  resist  upward  and  downward  traction  to  any  extent, 
while  small  intestines  can  be  freely  moved  in  every  direction  unless  adhesion 
has  taken  place.  Finally,  inflation  of  the  larger  bowel  with  air  will  cause  its 
distention  as  soon  as  relieved  from  its  fatty  environments. 

The  Fallacies. — The  colon  may  be  mistaken  for  a  loop  of  small  intestine, 
also  for  the  kidney,  especially  in  the  young  subject.  It  is  easily  distin- 
guished from  the  former  by  the  differences  already  stated;  from  the  latter, 
by  the  greater  density  of  the  structure  of  the  kidney,  its  rounded  extremi- 
ties, reniform  shape,  lobulated  appearance,  and  the  free  movement  of  the 
kidney  with  respiration.  Distention  of  the  bowel  by  gas  will  quickly  indi- 
cate its  individuality.  The  fat  beneath  the  transversalis  fascia  may  be  mis- 
taken for  the  subserous  fat,  and  consequently  the  transversalis  fascia  may 


684 


OPERATIVE   SURGERY. 


be  regarded  as  the  peritonaeum.  At  the  right  side  the  stomach  has  been  mis- 
taken for  the  colon ;  at  the  left  the  duodenum  for  the  colon.  The  physical 
characteristics  of  the  colon,  and,  finally,  the  prompt  distention  of  it  by 
insufflation,  should  quickly  correct  either  of  these  misapprehensions.  In  the 
instance  of  a  collapsed  colon  provided  with  a  mesentery,  the  peritonaeum  may 


escape  injury  if  the  bowel  be  distended  with  air  before  it  is  opened,  as  then 
the  entrance  to  it  may  be  made  between  the  mesenteric  folds. 

The  colon  may  be  misplaced  or  absent.     If  it  can  not  be  found  at  the 
left  it  should  be  sought  for  at  the  opposite  side,  and  opened  in  two  stages,  if 


OIMMJATIONS   ()X    VISCKltA    CONNECTKl)    Willi    i'KKI'roNMlUM.     OS;") 


pnictiL'al)K".  If  not  fumul  ul  all,  or  cliscovorud  at  a  jx^iiit  below  the  seat  of 
()l)stiiu'ti<)ii,  eiiterostoiny  sliould  he  praetineil.  A  protrusion  of  jjeritonaHjm 
into  the  woiuul,  eaused  hy  ascites  or  (h'i»ciiili'iit  on  a  long  mesocolon,  often 
gives  rist'  to  ninch  perplexity. 

Thr  /'rrji(ir(((iiii/  of  the  Pittient. — If  admissible,  thoi'onglily  cleanse  the 
bowel.  Place  the  patient  on  the  sonnd  side  near  the  edge  of  the  tabh;,  with 
the  loin  resting  on  a  hard  pillow  or  sand  bag.  Scrnb  and  cleanse  the  field 
of  operation  and  sunoiind  it  with  antiseptic  cloths  in  the  usnal  manner. 
Ether  is  commoidy  employetl  for  anajsthesia. 

The  OpiTittioii. — Make  an  incision  three  or  fonr  inches  in  length  in  the 
conrso  of  the  oblique  line  {c)  already  marked  out  (Fig.  8*J7),  carry  it  through 
the  integument,  fascia,  and  thick  layer  of  fat  usually  found  at  this  situation, 
down  to  and  through  the 
latissimus  dorsi  (/)  and  the 
posterior  libers  of  the  ex- 
ternal and  internal  oblique 
and  transversalis  muscles  in 
their  order,  and  thus  bring 
into  view  the  outer  border 
of  the  qnadratus  lumborum 
incased  in  its  compartment 
of  the  lumbar  aponeurosis 
which  passes  outward  and  is 
continuous  with  the  trans- 
versalis muscle  (Fig.  898,  e)  ; 
carefully  divide  the  aponeu- 
rosis, avoiding  the  twelfth 
dorsal  nerve  as  it  passes  in 

front  of  the  quadratus  lumborum  to  gain  the  transversalis  muscle.  Draw 
apart  the  borders  of  the  aponeurosis,  along  with  the  borders  of  the  incision, 
with  broad  retractors  or  deep  retraction  sutures  carried  through  the  entire 
thickness  of  the  borders  of  the  wound.  The  fatty  tissue  lying  between 
the  aponeurosis  and  the  transversalis  fascia  is  now  exposed  and  pushed  aside. 
Divide  the  transversalis  fascia  and  bring  into  view 
the  subserous  fatty  tissue  {a) ;  open  and  push  this 
structure  aside  with  the  finger  and  handle  of  the 
scalpel,  thereby  uncovering  the  anterior  surface  of 
tlie  sheath  of  the  quadratus  lumborum  muscle, 
which  can  be  seen  lying  behind  it  (Fig.  899,  b). 
In  the  great  majority  of  instances  the  intestine 
will  appear  in  the  wound  as  soon  as  the  subserous 
fat  is  displaced  (Fig.  900).  If  the  gut  do  not  appear 
at  this  time,  insutflation  of  the  bowel  with  air  by 
means  of  an  ordinary  bellows  will  promptly  produce 
the  result,  and  it  is  then  rolled  outward  with  the 
fingers  from  beneath  the  quadratus  muscle — cutting  the  outer  border  of  the 
muscle  if  need  be — so  as  to  expose  its  inner  aspect,  which  is  recognized  by 


Fig.  899. — lUac  colostomy.  ".  Mil'-n.iu-  Tatty  tissue. 
b.  Quadratus  lumborum  muscle,  c.  Linear  guide 
to  colon. 


Fus.  !)00.— lluie  eulostomy. 
Quadratus  lumborum 
muscle  below.fatty  sub- 
serous tissue  pushed 
aside,  showing  colon 
above. 


086 


OPERATIVE   SURGERY. 


Fig.  901. — Iliac  colostomy, 
showing  colon  o[)cned 
and  borders  turned  out- 
ward. Deep  sutures 
laid  for  closure  of  ex- 
tremities of  wound. 


the  presence  of  the  longitudinal  band.  The  passage  of  the  index  finger 
through  the  subserous  fat  in  front  of  the  transversalis  fascia  at  the  anterior 
surface  of  the  quadratus  lumborum  to  the  psoas  muscle  (Fig.  898,  ^'),  and  its 
withdrawal  in  a  hooked  manner  with  the  body  of  the  patient  roiled  toward 
the  left  side,  with  or  without  pressui-e  in  front,  will  roll  the  bowel  outward 
into  view  when  other  means  have  failed  to  expose  it.  In  passing  the  finger 
inward  for  this  purpose,  the  outer  border  of  the 
kidney  will  be  felt,  and  the  finger  should  be  passed 
in  front  of  the  kidney  as  the  colon  lies  at  this  situ- 
ation. Verify  the  identity  of  the  colon  by  means 
of  the  numerous  tests  already  given  (page  683). 
Should  the  peritonaeum  have  been  opened,  close 
the  breach  with  catgut  sutures  if  it  can  be  done 
readily,  otherwise,  let  it  alone,  as  the  withdrawal 
of  the  bowel  will  close  the  opening  and  no  harm 
can  follow  if  the  operation  field  be  aseptic.  Draw 
the  gut  outward  to  the  surface  of  the  wound  by 
means  of  forcejjs,  aided  with  pressure  in  front  if 
necessary,  and  while  it  is  retained  in  this  position 
close  the  extremities  of  the  wound  with  silkworm-gut  sutures  that  shall 
include  the  tissues  of  the  borders  down  to  the  lumbar  fascia  (Fig.  901). 
Tie  these  sutures,  and  then  unite  by  sewing  the  surface  of  the  bowel  with 
the  deep  borders  of  the  wound  all  around,  the  sutures  passing  through  the 
muscular  wall  of  the  gut  (Fig.  883).  //'  the  case  is  urgent,  smear  the 
wound  and  surrounding  surface  freely  with  iodoformized  vaseline ;  place  the 
patient  on  the  back  and  open 
the  gut  longitudinally  with 
a  scalpel  sufficiently  to  ad- 
mit the  extremity  of  Paul's 
tube  (Fig.  892),  which  is  tied 
in  place,  thus  permitting  the 
contents  to  escape  into  the 
proper  receptacle  without 
soiling  the  wound.  If  to  the 
end  of  Paul's  tube  a  piece  of 
rubber  tubing  be  attached, 
the  discharges  will  be  car- 
ried still  farther  away.  In 
fact,  rubber  tubing  can  be 
employed  from  the  first  for 
the  purpose,  by  inserting  one  end  into  the  intestine.  The  amount  and  con- 
sistence of  the  intestinal  contents  will  depend  not  a  little  on  the  previous 
treatment  of  the  patient :  constipated  movements  attending  the  adminis- 
tration of  opium  and  copious  discharges  the  use  of  cathartics.  If  the  con- 
tents of  the  colon  are  compact,  the  borders  of  the  opening  are  united  to  those 
of  the  wound  of  the  abdomen  before  opening  the  gut  (Fig.  902),  if  not,  after- 
ward, thus  the  better  preventing  infection  of  the  wound. 


Fig.  902. — Iliac  colostomy.      Borders  of  colon  wound 
united  to  integuments  and  subcutaneous  tissue. 


OI'KIJATIONS   ON    VISCKItA    CONNECTKD    WI'I'II    I'KKI'I'ON.ia'M.     (;y7 

If  (he  ntsc  is  imt  iiii/fii/,  [\\r  iiitcsl  iiic  wliuli  pulled  well  oiiLof  the  wound 
can  lu'  translixtMJ  with  \o\\<j;,  slim  pins  (Fig.  *.i'Z4),  inserted  tmnsversely 
tliroiii,')!  the  wall  wilhout.  penetnition  of  tlu;  liiinon,  al)oiit  tliree  ffMirtlis  of 
iin  ini'li  apart,  the  extremities  restin;^  (inally  on  iodoform  gauze  plae(!(l  at 
either  horder  of  the  wound.  The  margins  of  tiie  wound  are  then  carefully 
closed  with  chroniici/.ed-eatgut  or  silkworm-gut  sutures,  and  the  walls  of  the 
bowel  uniteil  at  the  sanie  time  to  the  cutaneous  border  of  the  wound  with 
fine  sutures  of  the  same  kind.  'IMie  parts  are  covered  with  proj)er  dressings, 
which  after  four  or  five  days  are  renewed,  and  a  crucial  opening  is  made  with 
a  pointed  bistoury  between  the  pins.  This  metliod  of  practice  divides  the 
operation  into  two  stages,  thus  lessening  greatly  the  liability  of  local  wound 
infection  and  its  frequent  and  unft)rtunate  sequels. 

77/f  Precautions. — Avoid  mistaking  the  stomach  at  the  left  and  the 
duodenum  at  tlie  right  for  the  colon.  A  disj)laced  and  hypertroi)hied  loop 
of  suudl  intestine,  or  a  prolapsed  long  mesocolon,  may  simulate  the  colon. 
If  the  wound  be  deep  and  the  intestine  be  drawn  taut  when  fastened  to  its 
borders  the  sutures  should  be  supplemented  with  pin  support  to  hold  the 
gut  securely  in  place.  Jf  scybalous  matter  be  present  at  the  opening  it 
should  not  be  disturbed  unless  necessary,  and  then  with  extreme  caution, 
until  firm  union  of  the  parts  is  established.  The  opening  should  be  made 
as  small  as  practicable  to  avoid  subsequent  prolapse  of  mucous  membrane, 
and  the  diet  of  a  kind  to  obviate  constipation.  The  patient  should  lie  u])on 
the  back,  or  toward  the  wounded  side,  until  the  union  of  the  parts  will  safely 
withstand  the  traction  of  different  postures. 

77ie  Remarks. — If  the  colon  can  not  be  found  at  the  loin,  it  should  be 
sought  for  through  a  median  incision,  and,  if  diseased,  returned  to  the 
proper  place  and  treated  as  before.  Or,  what  is  better,  open  the  sigmoid  in 
front  if  practicable.  If  neither  of  these  measures  be  advisable,  the  caecum 
can  be  entered  through  a  median  incision,  or  one  made  at  the  side  as  already 
described.  Enterostomy  can  be  practiced  if  the  other  plans  offer  no  relief, 
but  with  a  dubious  outcome.  If  fsecal  matter  enter  the  distal  segment  of  the 
intestine  and  cause  trouble,  it  can  be  turned  aside  entirely  by  closure  of  the 
upper  end  of  this  part  with  mucous  membrane  displaced  from  the  upper 
opening  and  fastened  in  place  with  sutures  (Jones).  The  entire  division  of 
the  gut  is  to  be  avoided,  since  peritoneal  infection  is  very  liable  to  arise  from 
this  measure.  Many  other  complications  of  this  operation  occur,  that  are 
foreign  to  iliac  colostomy,  and  the  large  number  of  perplexing  contingencies 
already  stated  only  emphasize  the  greater  utility  of  the  iliac  route  of 
entry. 

The  After-treatmeut . — The  patient  should  remain  in  bed  quiet,  subsist- 
ing on  a  simple  regimen,  until  the  immediate  dangers  of  the  operation  are 
gone  and  firm  union  of  the  parts  is  established.  ^Measures  to  promote  clean- 
liness and  prevent  irritation  of  the  parts  are  of  constant  importance.  The 
regulation  of  the  diet  to  sustain  the  patient,  keep  the  bowels  soluble,  and  the 
discharges  unirritating,  are  significant  desiderata.  When  the  wound  is  healed 
control  of  the  opening  is  secured  quite  as  well  by  simple  pads  fashioned  by 
the  patient  to  meet  the  needs  which  his  experience  suggests,  as  by  those 


688  OPERATIVE   SURGERY. 

planned  only  on  the  basis  of  theory.  As  a  too  small  opening  means  faecal 
dribbling,  the  opening  should  be  maintained  at  proper  size  by  dilatation  with 
the  finger,  laminaria,  or  by  special  apparatus. 

The  Results. — The  rate  of  mortality  is  variously  estimated  from  30  to  38 
per  cent.  Somewhat  recently  (1884r)  Dr.  Batt  reported  244  cases  with  a 
death-rate  of  a  little  more  than  3U  per  cent.  However,  tliese  figures  can  not 
be  regarded  as  indicating  the  results  of  more  advanced  thought  and  method. 
The  later  reported  experiences  of  Cripps  and  others  are  far  in  advance  of 
those  reported  by  Batt. 

Right  Lumbar  Colostomy. — Lumbar  colostomy  at  the  right  side  is  in- 
deed rarely  performed,  and  then  as  an  emergency  measure.  The  objections 
to  the  anterior  opening  at  the  right  side  apply  with  equal  force  to  the  poste- 
rior one  at  the  same  side.  The  colon  is  associated  more  directly  with  the 
abdominal  w^all  at  this  than  at  the  left  side,  as  a  mesocolon  at  the  right  side 
is  ten  per  cent  less  frequent  than  that  at  the  left  (Fig.  898).  The  technique 
of  the  operation  is  similar  to  that  of  the  left  in  all  the  stages,  but  the  results 
are  less  propitious  at  the  right,  for  easily  understood  physiological  reasons. 

The  Prognosis  in  Intestinal  Obstruction.— The  fatal  results  attending 
operations  for  intestinal  obstruction  are  truly  frightful,  and  are  caused  much 
more  by  meddlesome  medication  yoked  to  complacency  and  procrastination, 
so  often  seen  in  these  cases,  than  to  all  other  influences.  The  persistent 
administration  of  cathartics  and  alimentation  by  the  mouth  fills  prematurely 
to  overflow  the  proximal  segment  of  the  obstructed  intestine.  Finally,  pur- 
poseless delay,  associated  with  ever-increasing  accumulation,  and  infection 
causes  great  intestinal  distention  and  paralysis,  thus  introducing  new  ele- 
ments of  danger  to  the  patient  of  greater  moment  than  the  obstruction  itself. 
As  can  be  easily  conjectured,  the  varied  conditions  of  the  patients  represent 
every  phase  of  involvement  from  the  inception  to  final  collap.se,  when  the 
surgeon  is  called.  It  follows,  therefore,  that  difl'erent  methods  of  attain- 
ment of  the  object  must  be  practiced  in  order  to  prolong,  if  not  to  save, 
the  patient's  life.  In  the  majority  of  cases  an  operative  procedure  based  on 
complete  scientific  technique  can  not  be  practiced  at  the  outset  without 
imminent  danger  to  the  patient. 

In  the  very  urgent  cases  the  object  should  be  to  relieve  the  overdistended 
bowel  at  once,  and  thus  bridge  the  chasm  between  an  inevitable  disaster  and 
a  hopeful  outcome. 

The  Treatment  in  these  Cases. — Before  operation  wrap  the  patient  in  hot 
blankets.  Surround  him  with  bottles  of  hot  water ;  give  hypodermatic 
injections  of  brandy,  strychnine,  etc.  Under  cocain  ana?sthesia  perform 
enterostomy  at  the  right,  low  down  or  at  the  median  line  below  the  umbil- 
icus, while  many  of  the  preceding  expedients  are  being  carried  into  effect ; 
introduce  the  finger  and  pull  out  a  loop  of  intestine  ;  hold  it  in  place  with 
the  finger  or  fix  it  in  the  wound  with  sutures,  as  time  will  allow  ;  open  it 
longitudinally  with  a  scalpel  or  evacuate  it  with  a  small  trocar  with  a  rubber 
tube  attached,  being  careful  in  either  case  to  prevent  faecal  escape  into  the 
abdominal  cavity.  Administer  hot,  stimulating,  and  nutrient  enemata,  and 
wash  out  the  stomach  with  hot  water  as  soon  as  practicable.    Put  the  patient 


OPERATIONS  ON    VISCKIfA    CONNECTKD  WITH    I'KKITON^.UM.     C89 

in  bed  surrouiuU-d  with  liot  bhinkets  or  bottles  of  hot  water,  followed  by  a 
liot  saline  enema. 

In  the  less  urr/eut  cases  asei)tic  teclinique  and  general  surgical  prepa- 
ration for  operation  can  be  made.  In  these  cases  the  stomach  should  be 
washed  out  thoroughly  before  operation,  especially  if  fa.'cal  vomiting  have 
occurred.  Anaesthesia  is  utilized  with  care,  and  may  be  promptly  supple- 
mented witli  a  small  hypodermatic  injection  of  morphin.  Usually  in  these 
cases  the  author  em})loys  chh^'oform,  since  it  is  more  agreeable,  of  quicker 
action,  and  less  liable  to  cause  vomiting.  The  incision  is  made  in  the  median 
line  and  as  nearly  as  possible  to  the  seat  of  the  obstruction,  and  large  enough 
to  admit  the  hand  freely.  Two  strong  retraction  sutures  are  passed  through 
each  side  of  the  wound  including  the  peritonteum  ;  each  is  then  looped  and 
given  in  charge  of  assistants.  The  borders  of  the  wound  are  separated 
widely  by  traction  on  the  sutures,  the  omentum  pushed  aside,  and  careful 
examination  is  made  for  collapsed  intestine  before  introduction  of  the  hand. 
If  collapsed  and  distended  intestine  be  noted  lying  in  contact  with  each 
other,  the  seat  of  the  obstruction  is  located  somewhere  in  the  line  of  con- 
tact of  these  differently  conditioned  portions  of  bowel,  and  probably  at  the 
right  of  tiie  patient  if  due  to  bands,  for  there  ]Meckers  diverticulum  and 
the  mischief-making  vermiform  appendix  are  found.  It  is  the  practice  of 
the  author  to  push  upward  the  distended  intestines  carefully  as  a  whole  by 
the  aid  of  broad,  thin  sponges  or  napkins,  through  an  incision  admitting  of 
this  procedure,  till  the  collapsed  ones  appear ;  then,  while  the  former  are 
held  upward,  follow  up  the  latter  to  the  point  of  obstruction.  By  this 
course  the  seat  of  obstruction  has  been  promptly  located,  and  the  tempta- 
tion to  eventration  has  not  been  experienced.  In  some  instances  partial 
removal  and  wrapping  of  the  intestines  in  hot  aseptic  cloths  was  practiced 
on  account  of  their  extreme  distention.  If  the  jejunum  alone  be  distended, 
the  empty  ileum  wall  be  overridden  and  pushed  into  the  pelvic  cavity,  and 
for  these  reasons  the  abdominal  distention  will  not  be  great,  especially  at  the 
lower  part.  The  degree  and  location  of  abdominal  distention  will  be  meas- 
ured quite  definitely  by  the  extent  of  the  involvement  of  the  respective  parts 
of  the  small  intestine.  The  condition  of  the  csecum  is  a  good  key  to  the 
solution  of  the  general  seat  of  obstruction,  for,  if  it  be  not  distended,  the 
seat  of  hindrance  is  in  the  small,  and  if  distended,  in  the  large  intestine. 
Therefore,  the  prompt  ascertainment  of  the  state  of  the  ca?cum  is  a  matter 
of  considerable  weight,  since  the  attention  is  then  quickly  directed  to  the 
portion  of  intestine  involved,  and  unnecessary  handling  of  the  structures 
and  delay  are  avoided.  The  state  of  the  vermiform  appendix  can  be  noted 
at  the  same  time.  The  ordinary  seats  of  hernial  protrusions  and  the  rare 
places  of  strangulation,  as  the  diaphragm,  the  transverse  mesocolon,  foramen 
of  Winslow  (Fig.  984),  etc.,  should  not  be  overlooked  in  the  course  of  exami- 
nation. In  cases  of  extreme  distention,  eventration  is  a  wiser  and  prompter 
procedure  than  the  forcible  introduction  of  the  hand,  attended  with  the 
danger  of  serous  membrane  rupture  and  quite  certain  failure  of  finding  the 
point  of  obstruction.  In  fact,  the  best  interests  of  the  great  majority  of  this 
class  of  cases  will  be  better  served  by  enterostomy  and  subsequent  repair  than 


690 


OPERATIVE   SURGERY. 


by  any  other  plan  of  procedure  (page  670).  Cases  of  obstruction  must  be 
treated  according  to  tlie  individual  demands  of  each.  In  one,  perhaps,  the 
tedious  process  of  nnraveling  and  returning  of  the  intestine  loop  by  loop 
may  be  practiced  in  the  search  for  the  impediment,  with  the  risk  of  going 
in  the  wrong  direction.  If  the  mesentery  be  straightened,  the  direction  of 
its  attachment  to  the  posterior  wall  of  the  abdomen  will  suggest  the  course 
of  the  intestines.  Irrespective  of  the  plan  pursued  to  find  the  hindrance, 
the  latter  should  be  removed  as  soon  as  found,  and  the  intestines  returned 
and  the  wound  closed.  Distended  intestines  attended  with  obstruction  and 
paralysis  should  be  evacuated  through  one  or  more  small  openings  made 
with  a  scalpel  at  different  situations  (enterotomy),  which  are  then  promptly 
closed  by  sewing.  The  method  of  return  of  the  intestine  has  already  been 
described  (page  OGG),  along  with  the  additional  technique  of  treatment.  In 
no  instance  should  abdominal  distention  be  present  during  or  immediately 
after  the  closure  of  the  abdominal  wound.  If  overdisteution  prevent  the 
locating  of  the  seat  of  the  obstruction,  or  the  return  of  the  intestines  to  the 
belly,  free  incision  of  one  or  more  of  the  distended  loops,  and  emptying  out 
of  their  contents,  will  meet  not  only  the  preceding  requirements  but  also 
prevent  the  evil  influences  of  vigorous  handling  of  the  intestines  and  of 
autosepsis,  likewise  the  disturbances  of  thoracic  functions,  so  commonly  asso- 
ciated with    abdominal  distention.      Greig  Smith  advised  that,  in  suitable 

cases,  after  the  removal  of  the  obstruction  the 
distended  intestines  be  emptied  by  the  with- 
drawal of  a  loop  and  patiently  utilizing,  through 
a  good-sized  needle  thrust  into  the  bowel,  the 
force  of  aspiration.  By  this  plan  tlie  fluid  and 
gaseous  contents  can  be  withdrawn  in  about  half 
an  hour,  provided  the  suction  be  aided  by  gentle 
manipulation  and  contraction  of  the  walls  of 
the  bowel.  lie  believed  that  the  leaving  of  a 
loop  near  the  unclosed  opening  of  the  abdomen, 
for  subsequent  operation  if  needed,  to  be  better 
practice  than  uniting  the  intestine  to  the  walls. 
The  Removal  of  the  Cause  of  Obstruction. — 
The  general  technique  of  removal  of  the  vari- 
ous causes  of  intestiiuil  obstruction  differs  in  no 
essential  degree.  The  only  changes  in  both 
general  and  special  methods  of  action  relate  to 


Fi(i.  903. — Single  intussuscep- 
tion, vertical  section.  a. 
The  apex.      6,  h.  The  neck. 

c,  c.    The    entering    layers. 

d,  d.  The  returning  layers,    the  operative  requirements  of  the  different  ob- 
canddTheintussusceptum.    structive  conditions  and  to  the  devious  compli- 
cations that  often  appear  in  these  cases. 

Intussusception. — In  intussusception  an  up- 
per portion  of  tlie  intestine  is  invaginated  into 
the  lower ;  the  reverse  is  seldom  noted.     Invagi- 
nations are  usually  single  (Figs.  903  and  905),  may  be  double  (Fig.  904), 
and   sometimes  of  a  triple  character.     The  outer  part  or  sheath  is  denomi- 
nated the  intussuscipiens,  the  inner  or  invaginated  part  the  intussusceptum. 


e,  e.  The  intussuscipiens. 
/, /.  The  peritonaeum,  g,  g. 
The  muscular  coat  of  intes- 
tine, h.  h.  Mucous  mem- 
brane of  intestine. 


ol'KKA'I'loNS   OX   VISCKItA    COXNECTKI)   WITH    I'ERITONiEUM.     ♦;<)! 


I 


Fig.  904.— Double 

intussusception. 
a.  Tlie  upper  in- 
Viigiuiited  por- 
tion, b.  The 
lower  portion  of 
the  bowel. 


Enteric  iiivugiiuitions  lia]»|)C'n  in  .'Jo  j)C!r  (-cnl,  colic,  incliiding  Llie  rectal,  18 
per  cent,  ileo-ca3cal  44  per  cent,  and  ileo-colic  8  per  cent  of  the  cases.  In- 
tussusce])tion  i.s  a  prolific  cause  of  intestinal  obstruction  at  all  ages  (30  per 
cent),  especially  before  eleven  years  of  age,  when  it  reaches  53  per  cent. 
Only  about  half  (48  per  cent)  of  the  cases  are  acute,  the 
remainder  are  subacute  (34  per  cent)  and  chronic  (18  per 
cent).  The  seat  of  the  intussusception  is  at  the  ileo-caical 
region  in  45  per  cent,  in  the  colon  in  18  per  cent,  and  the 
small  intestine  in  about  12  per  cent  of  the  cases.  The  prog- 
nosis is  very  grave  at  the  best,  since  70  per  cent  terminate 
fatally,  and  three  fourths  of  these  succumb  within  seven 
days  of  the  attack  (Treves).  Two  methods  of  treatment 
are  advised  :  1,  disinvagination  by  distention  of  the  bowel 
with  gas  or  fluid,  aided  by  anassthesia  and  manipulation ; 
2,  abdominal  section  with  either  (a)  manipulative  disin- 
vagiiuition ;  (b)  intestinal  aiuistomosis ;  (c)  artificial  anus, 
with  or  without  resection ;  or  (d)  resection  of  the  intus- 
susception and  enterorrhaphy. 
7'he  ilistention  of  the  intestine  by  either  of  the  preceding  methods  after 
two  or  three  days'  duration  of  the  invagination,  or  in  the  presence  of  acute 
symptoms  of  even  a  lesser  period,  offers  but  little  encouragement,  indeed,  of 
a  favorable  outcome,  and  when  i)racticed  the  effort  is  made  tentatively  and 
briefly  rather  than  with  the  assurance  and  repetition  often  permissible  at  an 
earlier  period.  In  either  method  the  patient  should  be  anaesthetized  and 
the  distending  force  slowly  exercised  through  the  medium  of  a  rubber  tube 
passed  well  up  into  the  bowel,  and  held  there  by  pressure  against  the  but- 
tocks, so  as  to  prevent  the  escape  of  the  dis- 
tending agent  along  the  course  of  the  tube.  Air 
and  gas  can  be  forced  by  the  ileo-ca^cal  valve, 
and  are  therefore  useful  in  intussusception  of 
the  small  intestines  as  well  as  the  large.  Water 
{saline  solution),  however,  can  not  be  forced  by 
the  valve  with  safety  to  the  patient,  and  conse- 
quently is  useful  only  in  invagination  involving 
the  large  intestine.  The  manipulation  of  the 
"sausage-shaped  "  tumor  indicating  the  seat  of 
invagination  is  of  questionable  utility,  and  should 
be  carefully  practiced  by  rolling  the  tumor  from 
side  to  side,  gently  squeezing  it,  pressing  back- 
ward at  either  end  while  the  tumor  is  held  as 
gently  as  possible  with  the  hand.  At  all  events, 
whatever  is  done  in  this  regard  should  be  done 
gently,  and  be  relinquished  promptly  after  trial. 

The  Distent  10)1  with  Air.— In  this  instance  the  rubber  tube  is  connected 
with  a  bellows  which  is  slowly  worked,  while  attended  with  a  careful  inspec- 
tion of  the  abdomen  to  determine  the  seat  of  obstruction  by  noting  the  line  of 
ascending  distention  if  it  be  not  obscured  already  by  obstruction  tympanitis. 
50 


Fig.  905. — Single  intussuscep- 
tion, transverse  section,  a. 
The  entering  layer  of  intus- 
suseeptuni.  e.  Space  be- 
tween entering  and  return- 
ing layers  of  intussuscep- 
tuni.  /.  Lumen  of  entering 
segment,  d.  Space  between 
returning  layer  of  intussus- 
ceptum  and  inner  surface  of 
intussuscipiens.  c.  The  in- 
tussuscipiens. 


^92  OPERATIVE   SURGERY. 

The  Distention  luith  Carbonic-acid  Gas. — For  this  purpose  3  drachms 
of  bicarbonate  of  soda  and  4^  drachms  of  tartaric  acid  are  dissolved  sepa- 
rately in  water,  and  portions  of  either  solution  are  passed  alternately  into 
the  tube  at  intervals  of  six  or  seven  minutes  (Zienissen).  These  solutions 
are  employed  thus  slowly  to  obviate  any  danger  of  overdistention  incident  to 
a  too  rapid  generation  of  the  gas.  The  phenomena  incident  to  this  method 
of  distention  are  scrutinized  with  the  same  care  as  in  the  preceding  instance. 

The  Distention  with  Hydrogen  Gas. — An  ordinary  rubber  balloon  with 
a  capacity  of  from  two  to  four  gallons  is  the  simplest,  safest,  and  most 
efficient  instrument  for  making  rectal  insufflation  (Senn).  The  balloon  is 
connected  by  a  metal  tube  to  a  rubber  one,  and  the  gas  is  slowly  discharged 
through  the  latter  into  the  bowel  by  compression  of  the  bag  with  the  hands. 
The  balloon  is  a  better  agent  by  far  for  the  introduction  of  air  than  the 
bellows  or  any  mechanism  of  a  less  deliberate  action.  The  gas  should  be 
discharged  slowly  through  a  stopcock  easily  regulated  and  of  a  caliber  not 
larger  than  a  line  or  two  in  diameter  at  the  point  of  exit.  During  the 
introduction  of  the  gas  the  patient  should  lie  on  the  back  to  afford  the  sur- 
geon the  opportunity  to  outline  the  course  of  distention,  and  especially  to 
recognize  the  passage  of  gas  through  the  ileo-ca^cal  opening,  which  is  indi- 
cated by  a  gurgling  sound  that  not  infrequently  can  be  heard  several  feet 
away  from  the  patient.  A  sudden  lessening  of  the  pressure  in  the  use  of 
either  agent  indicates  that  disinvagination  has  taken  place,  or  that  rupture 
of  the  intestine  has  happened.  If  the  latter  have  occurred  the  escape  of 
gas  from  the  intestine  into  the  peritoneal  cavity,  together  with  the  addi- 
tional amount  slowly  introduced  through  the  tube  under  low  pressure,  will 
cause  a  general  tympanitis  with  loss  of  liver  dullness;  increasing  dullness 
on  percussion  indicates  the  escape  of  fluid ;  while  in  disinvagination 
decreased  pressure  is  followed  by  continued  upward  intestinal  distention  in  a 
regular  manner,  and  the  presence  of  liver  dullness. 

The  Distention  with  Fluid. — As  before  remarked,  the  benefit  of  liquid 
distention  is  limited  to  involvement  of  the  colon.  The  common  method  of 
practice  is  to  pour  the  fluid  into  a  funnel  held  about  three  feet  above  the 
patient  and  connected  directly  with  the  outer  end  of  the  intestinal  tube. 
The  fountain  syringe  can  be  employed  instead.  The  patient  need  not  be 
inverted  during  the  administration.  The  capacity  of  the  colon  in  the  adult 
is  from  a  gallon  to  a  gallon  and  a  third.  In  the  infant  from  ten  to  twenty 
ounces.  The  introduction  of  the  fluid  should  be  done  slowly,  with  the  head 
placed  low  and  the  pelvis  raised.  Sometimes  this  plan  is  practiced  without 
the  use  of  an  ana?sthetic.  Lukewarm  saline  solution  is  commonly  employed, 
but  warm  oil  can  be  used  instead. 

The  Remarks. — Prolonged  distention  with  low  pressure  is  more  service- 
able and  less  risky  than  rapid  distention  with  high  pressure.  It  is  impossible 
to  estimate  definitely  the  amount  of  fluid  and  the  degree  of  pressure  that 
will  cure  or  can  be  safely  borne  in  all  cases.  If  rupture  happens,  abdominal 
section  must  be  done  at  once.  Strong  objections  are  made  against  the  use 
of  any  distending  agent  by  some,  because  of  the  uncertainty  and  delay  of 
relief,  the  danger  of  rupture,  the  deceptive  results,  and  the  fickleness  of  cure. 


Ol'KKA'I'loNS  ON    VlSCKliA    CONXECTHD    WITH    I'KUI'I'oN.KL'M.     (;0;> 


The  Jifsults. — Tlio  einiiloyiiient  of  either  of  the  preeeiling  ineiisiires, 
before  adliesiou  shall  Iiuvg  taken  ])lace  between  the  invaginated  portions,  is 
commendable.  The  earlier  the  use,  the  safer  and  the  more  favorable  is  the 
outcome.  After  two  or  three  days  have  elapsed,  the  prospect  of  benefit 
and  the  danger  of  the  attempt  are  inversely  proportioned.  The  employ- 
ment of  gas  or  air  olTers  the  best  means  of  treatment  with  a  minimum 
danger  of  use,  provided  proper  care  be  exercised  in  the  administration. 
And,  too,  their  infiuence  is  more  extended  than  that  of  fluids,  as  the  effect 
of  the  hitter  is  limited  to  the  large  intestine  alone.  Still,  the  circumstances 
attending  the  case  often  require  the  utilization  of  fluids  as  the  simpler  and 
more  available  means  of  treatment.  In  72  cases  of  all  degrees  of  severity 
reported  by  Wiggin,  intestinal  distention  failed  in  54  instances.  Barker 
re})orted  42  cases,  11  of  which  were  treated  by  injection  only,  with  9  recov- 
eries ;  It!  cases  in  which  injection  failed  were  treated  by  abdominal  section, 
with  8  recoveries  ;  15  cases  by  abdominal  section  only  with  7  recoveries.  In 
50  cases  treated  by  distention, 
the  average  time  from  the  onset 
of  the  obstruction  is  three  hours 
and  a  half  in  the  successful 
cases  and  about  forty  hours  in 
the  unsuccessful. 

Abdominal  section  (page  607 
et  seq.)  should  follow  promptly 
in  these  cases  after  failure  of 
the  preceding  means  of  treat- 
ment with  the  view  of  securing 
relief  by  other  and  more  active 
measures.  The  age  of  the  pa- 
tient is  no  bar  to  the  attempt, 
for  all  ages  have  been  rescued 
by  the  measures  which  at  this 
time  offer  the  main  hope  of 
relief.  It  is  proper  to  say, 
however,  that  the  successful 
issue  will  depend  largely  on 
the  promptness  of  the  perform- 
ance, and  the  knowledge  and 
the  ability  to  carry  into  ef- 
fect the  requisite  surgical  tech- 
nique. 

The  Rediiction  by  Manipu- 
lation.— For  this  purpose  the 
abdominal  incision  should  be 
made  in  the  median  line  as 
near  as  possible  to  the  site  of 
the  tumor,  and  long  enough  to  permit  of  prompt  and  effective  handling  of 
the  invaginated  part.     After  exposure  of  the  seat  of  the  intussusception  and 


Fig. 


006. — Single  intussusception,  longitudinal 
section.  Showing  the  relations  of  the  impor- 
tant parts  of  the  intussusception. 


694 


OPERATIVE  SURGERY. 


its  careful  isolation  with  hot,  moist,  aseptic  surroundings  while  within  or 
after  withdrawal  (the  latter  preferable)  from  the  abdominal  cavity,  a  cau- 
tiously directed  eii'ort  at  restitution  by  manipulation  is  made  by  grasping 
the  tumor  between  the  hands  and  carefully  yet  firmly  squeezing  it  from  the 
base  to  the  neck,  so  as  to  reduce  the  size  of  the  edematous  intussusceptum, 
thus  enabling  restitution  to  follow  gentle  traction  at  the  neck  made  in  the 
long  axis  of  this  part  of  the  tumor  (Fig.  900).  If  adhesions  be  present 
between  the  serous  surfaces  of  the  invagination,  it  is  advised  by  some  sur- 
geons that  they  be  broken  up  by  a  blunt  probe  or  the  end  of  the  finger.     As 

the  constricted  neck  of  the 
tumor  will  hardly  admit 
the  end  of  the  finger  with- 
out causing  rupture  of  the 
gut,  and  as  the  presence 
of  adhesions  so  strong  as 
to  require  mechanical  sev- 
erance bespeaks  impossible 
reduction,  these  bits  of 
advice  should  be  accepted 
with  reluctance  and  be  ap- 
plied with  apprehension 
(Figs.  907,  90G).  Hutch- 
inson advised  that  the  in- 
tussuscipiens  be  drawn 
downward  instead  of  pull- 
ing the  intussusceptum 
upward,  as  is  so  often  rec- 
ommended. At  all  events, 
careful  traction  in  both 
directions  should  be  prac- 
ticed after  the  reduction 
of  the  oedematous  swell- 
ing by  squeezing,  never 
forgetting  that  a  too  vigor- 
ous or  prolonged  effort  at 
reduction  greatly  com- 
promises the  integrity  of  the  gut  and  depresses  the  vitality  of  the  patient, 
who  is  thus  perhaps  robbed  of  the  benefits  of  other  expedients  in  case  of 
a  failure  of  this.  After  restitution  of  the  intestine  to  its  normal  relations 
it  should  be  examined  carefully  to  detect  any  evidences  of  injury  or  points 
of  uncertain  vitality  that  may  be  present  and  require  surgical  attention. 
It  may  be  wiser  in  some  instances  to  isolate  the  parts  of  the  intestine  of 
questionable  vitality  with  iodoform  gauze,  and  leave  them  outside  of  the 
abdomen,  or  inside  even,  pending  Nature's  solution  of  the  doubt,  rather 
than  to  sacrifice  unduly  the  injured  portion,  or  the  patient's  opportunity 
of  recovery,  by  attempts  at  immediate  repair.  When  the  integrity  of  the 
gut  is  assured,  any  accumulation  of  faeces  or  gases  collected  in  the  prox- 


FiG.  907. — Intussusception  of  the  jejunum,     a.  Internal 
cylinder,     b.  Middle  cylinder,     c.  External  cylinder. 


OI'I'MJA'I'IONS    OX    VISCKIJA    CON  \  K(  "I'HI )    WITH     IMlKIToN  J-:UM.     (;c):, 

iniiil  portion  of  the  iiiti'sline  slioiild  be  cuusi'd  to  {)a.ss  ciloii;,^  the  ilisiiiva<,M- 
luitc'il  part  to  a  lioaltliier  j)ortioii  before  closure  of  the  abiloiiien,  in  order 
that  any  obstruct  ion  at  the  impaired  part  of  the  intestine  may  be  obviated 
until  the  fuiu'tion  of  the  bowel  is  restored.  A  failun^  to  reduce  the  intus- 
susception calls  prompt  attetition  to  the  advisability  of  the  adoption  of  other 
measures. 

The  Rcnutrks. — In  rare  instances  reduction  is  accomplished  easier  at  a 
later  tiian  at  an  earlier  period.  The  tumor  should  be  straightened  as  much 
as  })ossible  before  reduction  is  attempted.  Squeezing  the  intussuscipiens  at 
the  apex  of  the  tumor  is  serviceable.  Traction  on  the  intussusceptum  should 
be  avoided  in  severe  cases.  Circumscribed  thickening  of  the  gut  and  thick- 
ening of  tlie  ileo-ca^cal  valve  may  be  mistaken  for  incomplete  reduction,  re- 
quiring incision  to  nuike  the  distinction.  Small  doses  of  opium  should  be 
given  for  a  few  days  to  quiet  peristalsis  and  relieve  pain, 

Lafevdl  Afiasfomosis. — If  the  intussusception  be  a  small  one,  and  the 
involved  intestinal  structures  be  of  undoubted  vitality,  and  the  condition  of 
the  patient  admonishes  the  employment  of  a  brief  and  expedient  measure, 
one  loop  of  intestine  is  selected  at  the  proximal  and  another  at  the  distal 
aspect  of  the  obstruction,  the  surfaces  of  which  are  brought  in  contact  with 
each  other  longitudinally  and  without  tension,  and  joined  by  means  of  either 
the  decalcified  bone  plates  of  Senn,  the  round  or  oblong  button  of  Murphy, 
the  potato  plates  of  Dawbarn,  or  by  suturing,  as  ^^racticed  by  Halsted  and 
Abbe  (images  029,  G40  et  t<cq.).  Which  one  of  the  preceding  measures  should 
be  adopted  is  largely  a  matter  of  technical  expediency,  which  can  be  decided 
by  the  surgeon  himself  at  the  time  of  the  operation.  The  portion  of  the 
intestine  excluded  from  the  channel  of  frecal  flow  by  the  operation  appears 
thus  far  to  invite  no  unfavorable  outcome,  but  remains  both  inactive  and 
innocuous  to  a  satisfactory  degree. 

The  Establishment  of  an  Artificial  Anns. — Artificial  anus  may  be  estab- 
lished with  or  without  resection  of  the  invagination.  In  the  former  instance 
it  will  likely  take  the  place  of  a  completer  technique  (enterorrhaphy)  owing 
to  the  inability  to  properly  conclude  the  operation  as  at  first  intended.  Re- 
section is  not  permissible  in  the  presence  of  extensive  invagination  or  great 
prostration.  The  establishment  of  an  artificial  anus  irifhout  resection  is 
applicable  to  those  cases  in  which  a  fatal  outcome  would  soon  follow  a  more 
deliberate  procedure.  The  method  of  performance  is  described  under  the 
head  of  enterostomy  (page  G70  et  seq.). 

The  Eemarhs. — Regarding  the  last  two  preceding  methods,  but  little  can 
be  said  in  their  favor,  as  the  former  leaves  behind  a  gangrenous  intussus- 
ceptum and  is  almost  always  fatal.  The  latter  plan  is  no  less  grave  than 
the  former.  Either  may  prolong  life,  but  neither  is  at  all  likely  to  efifect 
a  cure. 

Resection  with  Enterorrhaphij. — The  resection  of  the  involved  segment, 
and  the  union  of  the  divided  ends  of  the  intestine  by  sewing  or  by  the 
circular  button  of  Murphy,  has  a  limited  application,  and  is  not  advisable  in 
the  presence  of  a  knowledge  of  the  more  rational  plans  of  Maunsell,  Barker, 
or  Paul. 


696 


OPERATIVE  SURGERY. 


The  Remarks. — The  results  of  resection  of  the  intussnsceptum  and  union 
of  tlie  divided  ends  by  tiny  method  are  of  the  gravest  character,  being  almost 
uniformly  fatal.  A  patient  able  to  bear  this  operation  is  quite  likely  to  be 
rescued  by  either  of  the  following.  However,  if  the  intussuscipiens  be  gan- 
grenous, this  course  must  be 
<^  taken,  and  end-to-end  union, 

or  lateral  implantation  of 
small  intestine  into  a  healthy 
part  of  the  colon  practiced, 
followed,  perhaps,  by  tempo- 
rary colostomy  of  the  cut  end. 
Maunsell  (Fig.  908)  ad- 
vised that  a  longitudinal  in- 
cision (c,  c)  be  made  through 
the  intussuscipiens  (1)  down 
upon  the  intussusceptum,  and 
that  the  latter  be  drawn 
through  this  opening  suf- 
ficiently to  bring  the  apex  («,«) 
and  neck  (Z*,  h)  of  the  invagi- 

FiG.  908. — The  treatiiu'ut  of  intussusception,  Maun-  nation  well  into  view,  and  then 

sell's  method.     1.  a,  a.  Apex  of  intussusceptum  j    j^  ^^.     -^      j         ^j^-j^  ^^^ 
&>.  Neck  ot  intussusceptum.    c,  c.  Longitudinal  ,.,..,  ^-  , 

incision  through  intussuscipiens.     2.  o.  a.  Point  neck    IS    divided     transversely 

of  division  of  neck  (dotted  line).     6,  h.  Sewing  ^^^^.^gg    /  g)   and   the  open 

of  neck.     c,c.  Intussuscipiens.  -,   /,     ,    .-.x  •     \, 

ends  are  sewed  (6,  6,  3)  in  the 

manner  already  described  (page  626).     The  part  is  then  disinvagiuated  by 

gentle  traction,  the  longitudinal  opening  closed,  and  a  few  additional  sutures 

are  applied  at  the  neck  to  strengthen  the  union. 

Barker's  Method. — Barker's,  like  Maunsell's  method,  comprehends  the 
excision  of  the  intussusceptum  and  its  removal  through  an  incision  made  at 
the  convex  surface 
of    the    intussus- 
cipiens. 

The  opposed 
serous  surfaces  of 
the  entering  and 
receiving  portions 
at  tlie  neck  of  the 
invagination  are 
united  together  by 
a  continuous  su- 
ture of   fine  silk, 

carried    so    as    to    ^^^-   ^^^- — "^''^   treatment   of  intussusception,   Barker's  method. 
a.  Intussuscipiens.     b.  Sutures,    d.  The  divided  border  of  the 
include   the    sero-  intussusceptum.     c.  Divided  segment  of  intussusceptum. 

muscular  coats  of 

both  portions.     A  longitudinal  incision  is  then  made  at  the  convex  border  of 

the  intussuscipiens  down  upon  the  intussusceptum  (Fig.  908,  1,  c,  c)  of  suf- 


()i'i:i{.\'ri(>Ns  (»\  visciiuA  connecti:!)  wri'ii  I'KitiTONii'^UM.    097 


licit'iit  Iciiulh  to  pci'iiiiL  tlu'  I'L'iuly  remuviil  tliruii<;li  it  of  tliu  hitter  body,  wliich 
is  tlit'ii  ainpiitatcil  as  near  as  possible  to  the  upjx'r  end  ( F\g.  909).  Stout  silk 
li<;atiiivs  are  passed  through  the  walls  of  the  stiiiiip  (//)  and  tied  firmly,  to  koej) 
the  serous  surfaees  in  eontaet  and  control  the  lileediiig  ])(jints.  IJsuallv  four 
to  six  siitiii-('s  are  employed,  the  iiitrodu<'tioii  Ix'iug  so  timed  as  to  keep  pace 
with  eutiiug  away  of  liie  iutussust-eptum.  Tlio  last  suture  controls  the  cir- 
culation in  the  stum])  of  the  mesentery,  which  is  not  divided  until  after  the 
suture  is  tied.  The  part  is  then  cleansed,  dried,  dusted  with  iodoform, 
dropped  into  the  lumen,  the  longitudinal  incision  closed  as  in  Fig.  807,  and 
the  borders  of  the  abdomen  are  united  as  in  other  instances. 

1'//e  Pn'cattiions. — It  should  be  noted  whether  or  not  the  lumen  of  the 
intussusceptum  is  clear  before  the  longitudinal  opening  is  closed.  If  it  be 
impossible  to   remove  the  intussusceptum  after  section,  it  may  be  loo.sened 

and  permitted  to  come 
away  with  the  stools. 
If  the  stability  of  the 
technique  or  the  possi- 
bility of  gangrene  be 
suspected,  a  gauze 
drain  should  be  intro- 
duced from  w'ithout 
and   be    i)ermitted    to 

Fig.  910.— The  trciitinont  of  intussusception,  Paul's  method.    I'emaiu   until  the  dan- 
a.  Longitudinal   ojicning   in   intussuscipiens.     h.   Longi-    ger  is  passed, 
tudinal  opening  in  intussusceptum.     c.  Ligature  thrown  „      „  ^.^      ,. 

around  intussusceptum  and  spool.  ^  nuc  sviodification 

of  Barker's  method 
can  be  more  quickly  performed  than  the  latter,  because  a  spool  and  ligature 
are  substituted  for  sewing  in  the  removal  of  the  intussusceptum.  However, 
the  plan  is  not  practicable  when,  as  sometimes  happens,  the  lumen  of  the 
intussusceptum  will  not 
receive  the  spool.  The 
serous  surfaces  at  the 
neck  are  united  with 
sutures ;  a  longitudinal 
incision  through  the  in- 
tussuscipiens is  made,  as 
in  Barker's  operation 
(Fig.  909).  A  longitu- 
dinal incision  is  then 
made  into  the  lumen  of 
the  intussusceptum  of 
sufficient  length  to  ad- 
mit the  metal  spool, 
which  is  carried  into 
place  and  held  by  a  strong  suture  passed  around  the  intussusceptum  where 
it  grasps  the  spool,  and  tied  (Fig.  911).  The  intussusceptum  is  cut  away, 
the  longitudinal  opening  in  the  intussuscipiens  closed,  parts  are  returned. 


//'V^'' #'""'' 


r'lll'li'liTIII' 


Fio.  911. — The  treatment  of  intussusception,  Paul's  method. 
Longitudinal  section  showing  metal  spool  in  position. 


G98 


OPERATIVE  SURGERY. 


Fig.  912.— The  treatment  of  ileo- 
c.Tcal  intussusception,  Baracz's 
method.     Isohition  of  the  tumor. 


and  the  abdominal  wound  is  closed.  Tins  modification  seems  to  present  the 
alternative  between  quicker  practice  and  the  danger  of  prompter  and  more 
decided  intestinal  contraction. 

Irreducible  i?ivaginations  of  the  small 
into  the  large  intestine  can  be  treated  in 
various  ways  as  circumstances  will  permit: 
An  artificial  anus  can  be  established  at  the 
lowermost  part  of  the  small  intestine,  the 
distal  portion  of  which  should  be  sewed 
firmly  to  the  abdominal  wall,  and  even 
clamped  with  forceps,  to  oppose  any  further 
invagination.  The  employment  of  Maun- 
sell's  or  Barker's  method  of  treatment  may 
be  thought  proper  in  some  of  these  cases, 
even  though  the  intussusceptum  can  not  be 
entirely  withdrawn,  for  if  divided  it  may 
promptly  escape. 

Baracz  successfully  treated  a  case  of  irre- 
ducible ileo-caecal  invagination  by  isolation 
of  the  tumor  (Fig.  912),  and  repair,  by  lateral  anastomosis  of  the  closed  end 
of  the  ileum  with  the  colon,  above  the  point  of  occlusion  (Fig.  913).  As 
before  remarked,  no  ill  effect  appears  to  follow  the  retention  in  place  of  the 
occluded  portions  of  the  intestinal  tract. 

Prolapsed  i}ivagi7iations  are  treated  better  by  the  plan  of  Mikulicz  than 
by  the  older  methods  of  procedure  (Fig.  903).  Mikulicz  pulled  down  the 
intussusceptum  {ci)  until  its  upper  limit  appeared,  then  made  an  incision 

transversely  across  its  anterior  surface,  going 
carefully  down  to  the  peritoneal  covering  of 
the  returning  layer  (rf),  then  through  it  into 
the  peritoneal  cavity,  arresting  haemorrhage 
as  it  occurred.  The  adjoining  peritoneal 
coverings  of  the  two  layers  (entering  and 
returning)  of  the  intussusceptum  {c,  d)  were 
united  together  at  the  point  of  severance 
with  a  row  of  fine  silk  Lembert  sutures. 
After  a  similar  treatment  of  the  posterior 
half  of  the  surface,  the  intussusceptum  was 
removed  and  the  respective  coats  of  the 
inner  (entering)  layer  of  the  invagination 
(c)  were  joined  with  those  of  the  middle 
(returning)  layer  {d)  previously  divided, 
except  the  peritoneal  covering,  which  had 
been  already  united  as  a  preliminary  meas- 
ure. This  method  not  only  shuts  off  the 
peritoneal  cavity  above  the  point  of  constric- 
tion before  the  intestine  is  opened,  but  also  unites  firmly  the  respective 
layers  of   the  intestine  with  each  other,  thus  preventing  infection  of  the 


Fig.  913.— The  treatment  of  ileo- 
CcBcal  intussusception,  Baracz's 
method.  Isolation  of  the  tumor 
and  closure  of  the  divided  extrem- 
ities.    Enterocolie  anastomosis. 


OPERATIONS  OX  vis('p:ra  connectkd  with  im;i;itox^um.    <;<.»<> 

raw  surfiiceri  and  the  consequent  danger  of  non-union  and  peritoneal  in- 
flamtnation.  In  a  time  of  emergency  in  this  class  of  cases  a  stiff  tube  may 
be  passed  through  the  intussuseeptuni,  around  which  the  gut  is  ligatured 
at  the  upper  limit  with  a  strong  rubber  cloth,  causing  it  to  slough  away  as 
the  serous  adhesions  take  place. 

The  IiesiiUs  of  ('a'liafoini/  for  Acute  IntnsHiisceplioii. — "  Out  of  sixty-five 
cases  in  which  the  intussusception  could  be  reduced,  thirty-eight  died,  a 
mortality  of  fifty-eight  per  cent.  Among  the  children  of  this  group,  the 
mortality  was  sixty-six,  among  the  adults  forty-seven  per  cent.  Of  seven- 
teen cases  in  which  the  affected  bowel  was  resected  and  sutured,  only  two 
recovered,  both  adults.  Of  sixteen  cases  in  whicli  an  artificial  anus  was 
made  (with  or  without  reduction  or  resection  of  the  intussusception),  two 
cases  recovered,  also  both  adults"  (Curtis).  Prolonged  and  delayed  opera- 
tions are  nearly  always  fatal.  The  danger  of  relapse  after  reduction  of 
the  invagination  ought  not  to  be  overlooked.  To  prevent  relapse,  Senn 
advises  the  making  of  a  fold  in  the  mesentery  parallel  with  the  long  axis  of 
the  bowel,  and  sewing  it  in  position  with  silk  sutures,  carefully  avoiding  any 
impairment  of  the  circulation  of  the  intestine.  The  need  for  this  step  is  not 
generally  recognized. 

Volvulus. — Volvulus  consists  in  the  twisting  of  a  loop  of  intestine  on 
its  axis  so  as  to  obstruct  its  lumen  and  vascular  supply.  It  happens  more 
frequently  at  the  lower  part  of  the  ileum  and  at  the  sigmoid  flexure, 
because  at  these  parts  the  mesentery  is  the  longest.  The  sigmoid  flexure 
is  involved  in  about  a  half,  and  the  ileum  a  third  of  all  the  cases.  Vol- 
vulus occurs  about  four  times  as  often  in  the  male  as  in  the  female,  and 
usually  between  forty  and  sixty  years  of  a^'e  in  both  sexes.  Attempts 
are  often  made  to  untwist  the  intestine  by  external  manipulation.  How- 
ever, the  delay  in  diagnosis  and  the  uncertainty  of  the  direction  of  the 
twist,  makes  the  attempt  dangerous  and  success  impossible  at  the  outset. 
Abdominal  section  offers  the  only  rational  means  of  treatment  of  this 
obstruction. 

The  Operation. — Make  an  incision  in  the  median  line  large  enough  to 
admit  the  hand ;  draw  apart  the  borders  of  the  w^ound  by  means  of  traction 
sutures  passed  through  all  of  the  tissues  of  either  border ;  push  aside  the 
omentum  and  examine  the  field  for  distended  intestine,  which  is  usually 
seen  at  once ;  draw  out  of  the  wound  the  distended  portion  and  examine 
for  the  seat  and  direction  of  the  twist.  If  found,  it  should  be  untwisted  if 
possible.  If  much  distended,  the  contents  of  the  loop  and  of  the  intestine 
above  should  be  evacuated  through  a  short  longitudinal  slit  made  at  the 
convex  border  of  the  untwisted  gut  with  a  scalpel.  The  intestine  is  then 
washed  out  with  sterilized  water  or  Thiersch's  fluid,  the  opening  closed,  and 
the  intestine  returned.  If  the  loop  first  withdrawn  offers  no  solution  as  to 
the  seat  of  the  twist,  additional  loops  are  removed  in  their  order  and  evacu- 
ated, if  need  be,  until  the  seat  of  the  obstruction  is  felt  or  brought  in  sight. 
Whenever  a  distended  loop  interferes  with  the  untwisting,  the  evacuation 
of  the  contents  facilitates  the  manipulation,  saves  time,  and  lessens  the  dan- 
ger of  injury  to  the  gut.     If  it  be  impossible  to  unwind    the  pedicle  on 


700  OPERATIVE  SURGERY. 

account  of  adhesions,  after  the  volvuhis  is  evacuated,  either  of  the  follow- 
ing methods  can  be  practiced  : 

1.  Lateral  anastomosis  of  the  proxinuil  and  distal  parts  of  the  intestine 
as  near  to  the  seat  of  the  obstruction  as  practicable,  thus  removing  the 
obstructed  loop  from  the  line  of  faecal  flow  (Fig.  829). 

2.  Resection  of  the  loop  and  union  of  the  intestinal  extremities  by  the 
end-to-end  or  lateral  approximation  methods  (pages  G24,  G45). 

3.  The  establishment  of  an  artificial  anus. 

Which  of  these  expedients  is  entitled  to  precedence  will  depend  on 
the  condition  of  the  patient  and  the  equipment  of  the  surgeon.  If  the 
intestine  be  greatly  disturbed,  or  the  patient  be  much  depressed,  a  temporary 
artificial  anus,  followed  later  by  completer  repair,  affords  the  best  outlook 
(page  670). 

The  Remarks. — It  is  regarded  as  wise  to  evacuate  and  cleanse  the  over- 
distended  intestine  of  a  volvulus  after  reduction,  since  paralysis  and  soften- 
ing of  the  walls  of  the  gut  promptly  follow  this  condition,  and,  if  unrelieved, 
often  cause  continued  obstruction  there  from  loss  of  peristaltic  function  in 
the  presence  of  a  large  fa?cal  accumulation.  The  normal  attachments  and 
the  direction  of  the  sigmoid  mesocolon  cause  the  gut  to  flex  and  commonly 
turn  outward  to  the  left  when  distended  with  air  in  experimental  instances, 
a  fact  which  suggests  that  the  manipulation  for  the  reduction  of  volvulus  of 
the  sigmoid  be  directed  from  left  to  right.  In  volvulus  of  the  sigmoid  the 
abdominal  incision  must  be  made  of  a  liberal  size,  to  permit  of  the  prompt 
and  safe  withdrawal  of  the  gut  before  attempted  rectification.  The  employ- 
7nent  of  rectal  injections  and  the  introduction  of  the  hand  into  the  bowel 
should  not  be  practiced  except  for  the  purposes  of  diagnosis,  and  even  then 
the  hand  must  be  of  small  size — about  seven  inches  in  circumference — and 
be  inserted  with  great  care.  All  defects  in  the  structure  and  vitality  of  the 
gut  arising  from  volvulus  must  be  carefully  sought  for  and  repaired  before 
the  bowel  is  returned. 

The  Results. — Established  cases  of  volvulus  are  hopeless  if  left  to  them- 
selves, death  usually  occurring  in  the  first  week.  About  50  to  70  per  cent  die 
after  the  relief  afforded  by  abdominal  section.  Relapses  are  liable  to  happen, 
as  the  operations  for  cure  afford  no  protection  against  this  contingency.  The 
shortening  of  the  mesentery  by  making  a  longitudinal  fold  parallel  with  the 
long  axis  of  the  intestine,  and  fastening  it  in  place  with  silk  sutures  (8enn) ; 
fixation  by  the  sewing  to  the  abdominal  wall  of  the  sigmoid  mesocolon 
(Roux),  or  of  the  bowel  itself  (Gould),  and  the  fixation  attendant  on  a  tem- 
porary artificial  anus,  are  tested  methods  of  successful  practice.  Excision  of 
the  distended  loop  has  been  suggested  (Obolinski). 

Neoplasms. — Xeoplasms  not  infrequently  cause  intestinal  obstruction, 
irrespective  of  those  connected  with  the  rectum.  These  growths  offend  by' 
lying  upon  or  by  involving  tlie  intestinal  structure.  If  obstruction  arise 
from  tumor  pressure,  the  growth  should  be  removed  in  the  manner  best 
calculated  to  meet  the  requirements  of  good  surgical  technique.  If  the 
neoplasm  be  inseparably  connected  with  the  intestinal  structure,  the  portion 
of  intestiue  and  mesentery  involved  should   be   removed,  along   with  the 


UPKIiATloN'S   OX   VISf'KRA    CONNECTKI)   WTIMI    I'ERITOX.KUM.     7ul 


Stranjjculation 
caused  by  an  intestinal 
divertifuluni  which  had 
wound  and  fastened  it- 
self about  a  loop  of 
intestine. 


growth  iuul  t'iilarj,a'd  glumls,  ami  the  ends  of  tlie  divided  gut  united  by  end- 
to-end,  or  tlie  lateral  apposition  method.  If  the  patient's  condition  or  the 
extent  of  the  disease  do  not  warrant  resection,  tlie  growth  should  then  be 
excluded  from  the  intestinal  ohaniud  by  lateral  anastomosis  of  the  intestinal 
loops  continuous  with  the  growth,  in  such  a  manner  as  to  avoid  undue  trac- 
tion on  the  loops,  and  at  the  same  time  economize 
as  much  as  j)0ssible  in  the  length  of  the  intestinal 
tract.  The  technique  of  these  procedures  is  suflft- 
ciently  explained  already  under  the  consideration  of 
enterectomy  and  the  various  methods  of  intestinal 
union  (page  Go-4  et  seq.). 

Diverticula  (Fig.  'Jl-i),  bands  (Fig.  015),  ,sUif<, 
openings,  etc.,  cause  intestinal  obstruction  not  infre- 
quently. The  right  iliac  and  pelvic  regions  are  the 
special  seats  of  this  class  of  constricting  agents,  be- 
cause of  the  location  there  of  the  vermiform  appen- 
dix, Fallopian  tubes,  and  uterus,  whose  natural  ar-  Fig.  914 
rangemeutand  acquired  infirmities  contribute  large- 
ly to  the  frequent  presence  of  intestinal  pitfalls  in 
these  parts.  Meckel's  diverticulum  is  also  in  this 
vicinity,  and  its  agency  contributes  about  twenty- 
two  per  cent  of  the  entire  number  (hernia  excluded)  of  the  cases  of  obstruc- 
tion dependent  on  bands,  diverticula,  etc. 

The  abdominal  incision,  exposure  of  the  contents,  and  the  search  for  the 
seat  of  constriction  are  each  carried  out  in  accordance  with  the  previous  de- 
scription of  like  procedures.  The  right  side  should  be  examined  first  for 
apparent  reasons.  Bands  and  diverticula  should  be  removed  entirely  when 
possible ;  they  should  be  ligatured  outside  the  points  of  division  to  prevent 
any  bleeding  that  may  attend  their  severance.  The  division  of  a  patent  di- 
verticulum should  be  guarded  against,  since  by  this  occurrence  not  only 
blood  but  infecting  products  may  escape  into  the  peritoneal  cavity ;  the  open 
extremities  should  be  closed  by  inversion  and  sew- 
ing, the  same  as  in  dealing  with  intestines,  and  then 
returned  to  the  abdominal  cavity.  Comparatively 
little  trouble  attends  the  finding  and  treatment  of 
bands,  but  if  gangrene  of  the  intestine  be  present  or 
threatened,  the  case  then  assumes  a  graver  aspect. 
However,  the  detection  and  treatment  of  these  com- 
plications have  already  been  given  due  consideration. 
Abnormal  openings  in  the  mesentery,  omentum,  and 
abdominal  walls  should  be  closed  to  prevent  a  repe- 
tition of  the  infliction  resulting  therefrom.  Of 
course,  in  desperate  cases  the  technique  should  be 
abbreviated  in  a  degree  consistent  with  the  best  in- 
terests of  the  case.  As,  for  instance,  if  the  open  ends  of  a  diverticulum  be 
brought  out  through  the  abdominal  wound  and  fastened,  instead  of  closed, 
valuable  time  will  be  saved. 


Fig.  915. — Stran.fjulat  ion 
of  a  loop  of  small  in- 
testine by  a  long  liga- 
mentous band. 


702  OPERATIVE  SURGERY. 

llie  After-treatment. — The  after-treatment  in  operations  for  relief  of  the 
various  causes  of  intestinal  obstruction  differs  in  no  essential  regard  from 
that  commended  for  all  severe  abdominal  operations.  The  patient  is  placed 
on  the  back  with  the  limbs  in  a  tiexed  position,  and  kept  there  for  three  or 
four  days  at  least.  The  bladder  is  evacuated  with  a  catheter,  if  necessary,  at 
regular  intervals;  a  very  small  amount  of  milk  and  Vichy  or  of  koumiss  is 
given  daily  after  the  first  twenty-four  hours  for  the  first  week.  JSIutrient 
enemata,  and  rectal  injections  for  thirst,  are  sparingly  administered  during 
the  same  time.  If  intestinal  distention  occur  and  become  annoying,  the  rec- 
tal tube  can  be  introduced  high  up  at  intervals,  and  allowed  to  remain  for  a 
time.  Codein  or  a  small  amount  of  morphin  can  be  administered  occasion- 
ally to  lessen  pain  and  nervous  irritation.  The  bowels  should  be  encouraged 
to  move  voluntarily  rather  than  from  the  effect  of  cathartics ;  rectal  ene- 
mata when  discreetly  employed  answer  the  purpose  well. 

The  Results. — In  coeliotomy  for  acute  intestinal  obstruction,  68.9  per 
cent  die,  and  the  mortality  is  twenty-five  per  cent  greater  without  than  with 
the  removal  of  the  obstruction.  The  death-rate  following  a  complete  tech- 
nique (suturing  the  bowel)  is  the  highest  of  any  plan  of  action,  being  8G.G 
per  cent  (Curtis).  The  earlier  the  operation  the  more  favorable  is  the  out- 
look. 

Colectomy. — The  term  colectomy  expresses  the  excision  of  a  limited  por- 
tion of  the  colon  and  the  union  of  the  divided  extremities.  It  seems  wise, 
we  think,  to  extend  the  application  of  the  term  to  the  sigmoid  flexure 
also,  rather  than  employ  a  new  one  (sigmoidectomy)  definitely  applicable  to 
this  part  of  the  large  intestine,  a  course  not  in  harmony  with  the  general 
use  of  the  term  colostomy. 

The  Operation. — The  operation  of  colectomy  should  be  performed  as 
early  in  the  history  of  a  case  as  possible,  to  secure  the  best  result.  After 
thorough  cleansing  of  the  bowel,  the  incision  to  reach  the  ascending  or  the 
descending  portion  of  the  colon  involved  is  made  along  the  corresponding 
linea  semilunaris,  or  at  its  outer  side,  as  circumstances  require.  The  tumor 
is  exposed,  and  isolated  by  aseptic  surroundings,  the  contents  of  the  intestine 
are  pushed  away  from  the  distal  and  proximal  aspects  of  the  growth,  and  the 
bowel  is  clamped  with  forceps  or  tied  with  gauze  at  two  points  about  three 
or  four  inches  apart  at  each  of  the  respective  extremities,  the  two  inner 
sites  of  constriction  being  located  close  to  the  growth.  The  question  of  the 
ability  to  unite  the  divided  ends  of  the  gut  should  be  considered  carefully 
before  any  impairment  of  the  intestinal  structure  is  made.  If  the  extremi- 
ties can  be  united  either  by  end-to-end  sewing,  by  the  large  circular  button 
of  Murphy,  or  by  lateral  approximation,  without  undue  tension,  the  opera- 
tion is  continued  by  division  of  the  intestine  at  the  proximal  side  close  to 
the  inner  point  of  restraint,  and  the  divided  ends  are  cleansed  with  carbolic 
or  Thiersch's  solution  and  carefully  wrapped  in  iodoform  gauze.  The  dis- 
tal portion  is  treated  similarly,  after  which  the  two  ends  are  united  together 
by  aid  of  the  means  best  suited  to  the  case.  The  isolated  portion  of  intes- 
tine, along  with  the  growth  and  secondarily  resulting  defects,  are  removed 
as  in  resection  of  the  cfecum  (page  698),  and  the  wound  is  cleansed,  drained 


OTEIiATlOXS   UN    VISL'KItA   COXNKC'TKD    WI'l'll    I'KKITON JOUM.     703 


if  need  bo,  jiiul  .snitiibly  closed.  If  it  he  re<,'!ir(le(l  ;is  iiiiixj.ssible  to  unite  the 
divided  ends  of  the  eolou  safely  after  excision  of  the  growth,  either  of  the 
following  jihins  can  be  pursued  : 

1.  Primary  anastomosis  of  the  ileum  with  the  colon  (ileo-colostomy)  at 
the  lowest  practicable  point  beyond  the  seat  of  the  disease.  After  this,  the 
disease  can  be  removed  or  not,  as  circumstances  dictate.  If  not,  the  open 
ends  of  the  bowel  are  closed  and  returned  to  the  abdominal  cavity,  the  abdo- 
men is  closed  and  the  patient  committed  to  his  fate,  so  far  as  the  morbid 
growtii  is  concerned.  If  removal  be  practiced,  it  should  be  done  as  has 
already  been  described. 

2.  If  the  distal  end  of  the  colon  bo  beyond  the  reach  of  the  ileum  for  the 
purposes  of  proper  anastomosis,  either  one  of  two  courses  can  be  pursued  :  (a) 
the  closure  of  the  distal  end  of  the  colon  and  the  establishment  of  an  arti- 
ficial anus  at  the  seat  of  the  incision  by  the  withdrawal  and  fastening  out- 
side of  the  proximal  end  of  the  gut ;  or  (b)  the  closure  of  both  ends  of  the 
colon  and  the  anastomosis  of  the  ileum  with  the  descending  colon  or  sigmoid 
flexure  near  the  rectum.  If  the  plan  (/>)  is  practiced  the  sphincter  ani  sliould 
be  well  stretched  to  facilitate  the  discharge  of  faical  matter.  If  stretching 
is  not  done  the  rectal  contents  are  not  infrequently  carried  upward  along  the 
colon  and  small  intestine  by  the  expulsive  efforts  of  the  bowel,  instead  of 
downward  as  is  normal.  The  writer  has  had  an  experience  of  this  kind  in 
an  instance  of  ileo-sigmoid  anastomosis. 

Paul's  Method. — In  those  instances  of  colectomy  in  which  the  formation 
of  an  artiticial  anus  is  advisable,  Paul  commends  the  following  method  of 
practice  :  Through  a  free  incision  made  over 
the  site  of  the  tumor,  clean  away  the  adhe- 
sions, ligature,  and  divide  the  mesentery  well 
beyond  the  limits  of  the  growth ;  remove 
from  the  abdomen  the  loop  of  bowel  and  the 
associated  disease ;  sew  together  the  divided 
borders  of  the  mesentery  (Fig.  910)  and  the 
corresponding  adjacent  surfaces  of  the  intes- 
tine, thus  drawing  the  mesentery  outward, 
so  as  to  lie  beneath  the  bowel ;  make  an 
opening  into  the  colon  at  either  side  of  the 
disease  and  introduce  into  each  orifice  a 
large-sized  Paul's  tube  (Fig.  892),  ligature 
it  firmly  in  place,  cut  away  the  diseased  part, 
and  close  the  external  wound  with  deep  su- 
tures. Two  or  three  weeks  later  the  intes- 
tinal spur  is,  in  suitable  cases,  removed  by  the  enterotome,  and  the  artifi- 
cial anus  closed  in  the  usual  way  (page  G80). 

21ie  Remarks. — Gauze  packing,  to  prevent  infection  of  the  wound  after 
operation,  is  required.  The  proximal  tube  is  quite  sufiBcient  when  attended 
with  closure  of  the  distal  end,  which  closure  is  accomplished  independently 
or  by  inclusion  in  the  proximal  ligature.  Cripps  strongly  approves  of  the 
removal  of   the  diseased  coil  of  intestine    outside   of    the    abdomen,  and 


Fig.  016.— Colectomy.  PauFs  meth- 
od. Arrangement  of  bowel  to 
form  spur. 


704  OPERATIVE  SURGERY. 

its  retention  there  until  adhesions  have  shut  off  the  peritoneal  cavity  when 
resected.  Bloclt,  practices  a  similar  method  in  three  operations:  1,  the  dis- 
eased loop  is  fastened  outside  the  abdomen ;  2,  resection  and  enterorrhaphy 
are  practiced ;  3,  later  the  adhesions  are  separated  and  the  bowel  is  returned 
to  the  abdomen.  If  the  obstruction  is  acute,  an  opening  into  the  proximal 
aspect  of  the  bowel  can  be  made  so  soon  as  protective  measures  are  taken. 

Treves,  in  idiopathic  dilatation  of  the  colon,  in  a  child  about  six  years  of 
age,  carried  into  effect  in  1897  *  the  following  measures,  which,  because  of 
their  value,  we  will  freely  quote  : 

"  I  performed  laparotomy  on  January  13,  1897,  opening  the  abdomen  in 
the  median  line  below  the  umbilicus.  There  immediately  presented  a 
gigantic  coil  of  colon  which  looked  and  felt  like  the  adult  stomach,  and 
wliich  appeared  to  fill  up  the  whole  of  the  abdomen.  This  coil  was  at  once 
emptied  of  its  gas  through  a  small  incision.  The  wall  of  this  intestine  was 
smooth  and  much  thickened  by  hypertrophy,  and  the  actual  diameter  of  the 
collapsed  loop  was  eight  inches.  It  was  this  coil  which  had  practically  alone 
caused  the  distention  of  the  abdomen.  Further  examination  showed  that 
the  lower  part  of  the  bowel  corresponding  to  the  rectum  and  sigmoid  flexure 
was  represented  by  a  straight,  solid-looking  tube  about  the  size  of  an  adult's 
forefinger  and  some  eight  or  nine  inches  in  length.  This  tube  was  without 
sacculation,  and  its  longitudinal  muscular  coat  was  very  marked.  It  was  of 
uniform  diameter.  It  was  provided  throughout  with  a  short  mesocolon. 
There  was  scarcely  a  trace  of  fat  within  the  abdomen,  and  as  a  result  the 
blood-vessels  of  the  intestine  were  easily  identified.  The  junction  between 
the  dilated  gut  and  the  narrow  tube  was  quite  abrupt.  I  enlarged  the  little 
opening  I  had  made  into  the  colon  and  introduced  the  finger  to  examine  the 
interior  of  the  great  pouch.  Its  walls  were  smooth,  and  a  flaplike  fold  of 
mucous  membrane  occupied  the  orifice  that  led  into  the  narrow  tube.  This 
opening  readily  took  the  forefinger.  The  fold  of  mucous  membrane  may 
have  contributed  to  certain  of  the  obstructive  attacks  and  may  explain  the 
retention  of  certain  enemata.  In  examining  the  parts,  however,  it  appeared 
more  probable  that  the  attacks  of  obstruction  would  be  due  to  bending  or 
kinking  of  the  bowel  at  the  point  where  the  tube  and  the  great  sac  joined. 
The  length  of  the  narrowed  part  of  the  bowel  corresponded  to  the  length  of 
tube  which  experience  had  shown  was  necessary  to  produce  any  emptying  of 
the  great  pouch.  The  even  contraction  of  the  lower  part  of  the  bowel  may 
have  been  in  some  degree  due  to  the  constant  use  of  this  tube.  I  passed  a 
gum-elastic  tube  of  large  caliber  through  the  anus  and  along  the  narrowed 
rectum  well  into  the  interior  of  the  dilated  bowel.  The  tube  measured 
twelve  inches.  I  had  some  hope  that  if  it  would  be  kept  in  position  for 
some  time  the  distention  would  be  relieved  and  a  more  normal  action  of  the 
bowels  would  be  possible.  I  closed  the  opening  I  had  made  into  the 
descending  colon,  but  brought  the  suture  line  into  the  center  of  the  parietal 
wound  so  that  an  artificial  anus  could  be  established  at  any  moment.  This 
fixing  of  the  bowel  would,  I  hoped,  tend  to  prevent  it  from  becoming  kinked 

*The  Lancet,  January  29,  1898. 


Ul'KKATlUNS   UN    VLSC'KILV    CUNNKCTElJ    WITH    I'KKITON.ia'M.     705 

or  bent.  The  wound  in  the  parietcs  was  then  closed  in  all  but  its  central 
parts. 

"  For  some  days  the  abdomen  remained  free  from  distention  and  the 
child  from  pain.  Some  ftecal  matter  was  passed,  but  the  tube  became 
blocked  and  could  not  be  freed  ;  another  tube  could  not  be  properly  intro- 
duced, the  child  felt  the  worry  of  a  foreign  body  in  the  bowel,  and  at  the 
end  of  seven  days  the  use  of  the  tube  was  abandoned  and  an  artificial  anus 
established  in  the  center  of  the  median  wound.  Through  this  artificial 
opening  all  the  motions  were  i)assed  for  the  next  nine  months.  Practically 
nothing  cume  by  the  rectum.  The  distention  was  relieved  and  the  child 
was  free  from  the  continued  spasmodic  pains.  There  was,  however,  some 
difficulty  in  keeping  the  artificial  anus  open,  as  there  always  is  with  such 
openings  when  made  as  the  present  one  was  made.  This  necessitated  the 
introduction  for  so  many  hours  each  day  of  a  bent  rubber  tube,  which  kept 
the  orifice  quite  patent  but  which  occasioned  the  child  a  good  deal  of 
distress.  In  October,  1897,  I  resolved  to  attempt  the  excision  of  the  colon 
from  the  splenic  flexure  to  the  anus,  as  this  appeared  to  afford  the  only 
possible  prospect  of  giving  complete  relief  to  what  was  still  a  distressing 
condition. 

"  The  second  operation  was  performed  on  October  29th.  By  means  of 
an  elliptical  incision  in  the  skin  I  isolated  and  removed  the  artificial  anus, 
entering  the  abdomen  on  each  side  of  the  opening.  The  orifice  in  the  colon 
I  closed  by  a  series  of  substantial  sutures.  I  found  that  the  gut,  which  had 
at  one  time  been  so  enormously  distended,  was  now  of  more  moderate  dimen- 
sions, and  its  point  of  juncture  with  the  narrow  tube  which  represented  the 
lower  part  of  the  colon  was  still  abrupt.  The  narrowed  tube  had  shortened 
somewhat  as  the  result  of  removing  the  distention.  The  dilatation  of  the 
colon  extended  up  to  the  splenic  flexure.  Beyond  that  point  the  colon  was 
practically  normal,  although  it  had  evidently  been  to  some  degree  distended 
and  still  showed  some  hypertrophy  of  its  walls.  The  colon  on  the  right 
side  was  normal,  and  the  whole  of  the  greater  bowel  had  a  very  free  meso- 
colon. Having  found  that  I  could  bring  the  left  extremity  of  the  transverse 
colon  to  the  anus,  I  isolated  and  ligatured  the  left  colic  artery,  and  having 
clamped  the  bowel  divided  it  at  the  splenic  flexure.  I  then  isolated  the  sig- 
moid artery  and  the  superior  hfemorrhoidal  vessels  and  ligatured  them.  The 
absence  of  fat  in  the  retroperitoneal  tissue  rendered  this  proceeding  very 
simple.  At  the  same  time  I  ascertained  that  the  distribution  of  the  middle 
and  right  colic  arteries  was  normal.  I  then  excised  the  gut  representing 
the  descending  colon,  the  sigmoid  flexure,  and  the  upper  part  of  the  rectum. 
I  divided  the  bowel  low  down  in  the  pelvis  below  the  entrance  of  the  superior 
haemorrhoidal  artery.  A  few  bleeding  points  made  manifest  by  the  excision 
required  ligatures.  The  child  was  now  placed  in  the  lithotomy  position,  and 
having  made  an  elliptical  incision  around  the  evidently  narrowed  anus  I 
proceeded  to  remove  the  anus  together  with  the  lower  and  remaining  portion 
of  the  rectum.  The  separation  of  the  rectum  from  the  slender  vagina  was  a 
somewhat  tedious  matter.  The  middle  haemorrhoidal  vessels  were  secured 
and  the  lower  end  of  the  rectum  removed  without  difficulty.     I  returned  to 


YOG  OPERATIVE   SURGERY. 

the  abdominal  cavity  and  brought  the  transverse  colon  down  to  the  anus, 
where  I  secured  it  by  a  series  of  close  sutures.  The  gut  was  conducted  into 
position  by  four  pressure  forceps  which  were  passed  into  the  abdomen 
through  the  hole  in  the  perineum.  The  operation  was  concluded  by  closing 
the  wound  in  the  abdomen  without  drainage.  The  child  made  a  speedy 
and  excellent  recovery.  The  only  complication  was  represented  by  some 
suppuration  between  the  new  rectum  and  the  vagina.  This  was  no  doubt 
due  to  accidental  infection  of  the  tissues  while  drawing  the  transverse  colon 
into  place.  As  soon  as  the  child  began  to  run  about  again  this  discharge 
ceased  entirely."  Tlie  results  (Butlin)  of  operation  on  sigmoid  in  G-i  cases, 
26  deaths.  The  death  rate  of  sexes  about  equal.  Suture,  end  to  end,  21 
cases,  6  deaths ;  suture,  lateral,  1  case,  no  death.  Maunsell's  method,  2  cases, 
no  death.  Artificial  anus,  secondary  resection,  3  cases,  1  death.  Murphy's 
button,  3  cases,  3  deaths.     Block's  method,  2  cases,  no  death. 

Operations  on  the  transverse  colon  are  made  through  a  median  incision, 
and  liave  a  more  serious  outlook  than  those  of  the  remaining  parts  of  the 
large  intestine,  because  of  the  commanding  relation  of  this  portion  of  the 
bowel  to  the  peritoneal  cavity,  and  its  intimate  connection  with  the  jjerito- 
nffium  itself.  Infection  here  invites  general  disaster,  because  of  the  serous 
environments  and  their  direct  relation  to  the  peritoneal  cavity  at  large. 
However,  the  ample  serous  covering  of  the  intestine  yields  two  advantages  : 
the  opportunity  for  free  manipulation  and  for  prompt  serous  union. 

The  Comments. — Care  should  be  taken  to  bring  serous  membrane  in 
contact  around  the  entire  circumference  of  the  colon  along  the  line  of  union, 
in  order  to  secure  prompt  and  serviceable  attachment  of  the  divided  extremi- 
ties. The  point  of  exit  of  drainage  in  ascending  or  descending  colectomy 
can  be  so  located  posteriorly  as  to  be  dependent  and  substantially  outside  of 
the  peritoneal  cavity.  The  results  (Butlin)  in  transverse  colon  and  hepatic 
and  splenic  flexures  operations  in  82  cases,  29  deaths ;  death  rate  much  less 
in  females  than  males.  Suture,  end  to  end,  53  cases,  22  deaths ;  suture,  lat- 
eral, 2  cases,  no  death.  Maunsell's  method,  1  case,  no  death.  Artificial  anus, 
secondary  resection,  4  cases,  1  death.     Murphy's  button,  6  cases,  2  deaths. 

Resection  of  the  lleo-CsBCum. — The  resection  of  this  part  of  the  intestinal 
canal  is  practiced  for  the  cure  of  malignant  disease,  and  the  earlier  the 
attempt  is  made  the  brighter  will  be  the  outlook.  Deferment  of  operation 
until  symptoms  of  obstruction  appear  ought  not  to  be  contemplated  for  a 
moment,  since  this  course  offers  no  advantages,  but  profoundly  deejoens  every 
serious  aspect  of  the  case.     More  or  less  of  the  ascending  colon  is  removed. 

The  Operation. — After  thorough  cleansing  of  the  bowel  and  the  opera- 
tion field,  place  the  patient  on  the  back  and  make  an  incision  about  five 
inches  in  length,  beginning  in  the  line  of  the  anterior  border  of  the  axilla, 
at  a  point  midway  between  the  lower  border  of  the  costal  cartilages  and  the 
crest  of  the  ilium,  carry  it  downward  to  within  an  inch  and  a  half  of  the 
anterior  superior  spinous  process  of  the  ilium,  and  thence  obliquely  forward 
and  downward  an  inch  and  a  half  above,  and  parallel  with,  Poupart's  liga- 
ment to  a  point  opposite  the  middle  of  this  ligament.  The  tissues  of  the 
abdominal  wall  are  divided  in  consecutive  order,  the  abdominal  cavity  is 


()IM;i{A'ri()NS   ox    VISCKRA    (CONNECTED   WTI'II    I'KlilTON^UM.     707 


opened,  and  the  borders  of  the  wound  are  drawn  apart  by  means  of  retrac- 
tion sutures,  lieinove  adherent  omentum  by  division  between  tigiitened 
ligatures,  expose  the  h)W('rmost  part  of  tlie  ileum  and  its  junction  with  the 
colon  ;  strip  aside  the  eontcnts  of  the  lower  four  inches  of  the  sound 
ileum  with  the  tliumljs  and  lingers,  and  raise  this  ])ortion  of  intestine  from 
the  abdomen  ;  isohite  it  with  moist  antiseptic  sponges,  and  constrict  the 
extremities  of  the  emptied  part  witli  clamps  or  iodoform  gauze  passed 
around  the  gut  through  the  mesentery  and  tied  ;  divide  the  intestine  close 
to  the  seat  of  the  innermost  constriction ;  cleanse  the  divided  ends  of  the 
iutestine  witli  Thiersch's  fluid  or  carbolic-acid  solution,  and  surround  them 
with  iodoform  gauze.  Then  expose  for  four 
inches  the  ascending  colon,  strip  away  its 
contents,  and  constrict,  raise  up,  isolate,  and 
finally  divide  it  in  the  same  manner  as  the 
ileum  ;  unite  the  divided  ends  of  the  colon 
and  ileum  directly  by  Maunsell's  (Fig.  80G), 
the  oblique  end-to-end  sewing  metliod  (Fig. 
917),  or,  after  closure  of  both  ends,  by  lateral 
approximation  (page  640  et  seq.),  or  by  lat- 
eral implantation  of  the  ileum  into  the  closed 
(or  open)  end  of  the  colon  (page  049),  The 
distal  temporary  constricting  agents  are  now 
removed,  and  as  the  faecal  flow  is  allowed  to 
pass  along  the  newly  made  channel  the  oper- 
ator should  determine  that  no  leakage  is 
present.  The  parts  are  carefully  cleansed 
and  restored  to  the  proper  position.  If  the 
condition  of  the  patient  will  permit,  the  pa- 
tient is  rolled  somewhat  to  the  opposite  side 
and  the  resected  part  is  isolated  with  aseptic  surroundings.  Small  sections 
of  the  mesentery,  including  the  vessels,  are  then  tied  with  silk  ligatures, 
the  mesentery  is  severed  with  scissors,  and  the  segment  removed.  If  the 
patient's  condition  forbids  this  course,  the  constricted  ends  of  the  part  are 
brought  out  into  the  abdominal  wound  and  fastened  to  await  a  more  favor- 
able time  for  removal.  In  either  instance  of  removal,  infiltrated  structures 
and  enlarged  mesenteric  glands  should  always  be  taken  away  when  practicable. 
The  Remarks. — The  abdominal  incision  should  be  extended  promptly  in 
either  direction  if  a  too  limited  extent  interferes  with  inspection  or  proper 
manipulation.  Denuded  surfaces  in  contact  with  serous  membrane  should 
be  repaired  with  peritona?um  by  transplantation,  or  by  sewing  together  the 
serous  borders  of  the  denuded  area  if  feasible.  The  possible  technical  re- 
quirements arising  from  the  local  and  general  demands  of  a  case  should  be 
anticipated,  in  order  that  they  may  be  promptly  and  wisely  met  without  im- 
pairing the  chances  of  relief.  In  the  instance  of  small  tumors  giving  a 
chance  for  easy  inspection  of  the  mesocolon  at  either  side,  this  structure 
may  be  divided  between  ligatures  and  the  vessels  secured,  thus  liberating  the 
part  before  the  intestine  is  removed. 
51 


Fig.  917. — Oblique  end-to-end  sew- 
ing of  unequal  segments.  A. 
Colon.  B.  Ileum  obliquely  di- 
vided for  union  with  end  of  co- 
lon. C.  Longitudinal  division, 
with  or  without  trimming  of 
borders,  for  the  same  purpose. 


708 


OPERATIVE   SURGERY. 


Pig.  918. — Protective    gauze    packing   at   the 
seat  of  defective  intestinal  union. 


The  Precautions. — If  the  growth  be  adherent  to  the  abdominal  wall  at 
the  line  of  incision  it  will  be  freely  cut,  unless  the  anatomical  structures  in 
front  be  recognized  as  they  are  divided.  If  the  tumor  be  thus  adherent,  it  is 
better  to  extend  the  incision  above  or  below  to  a  point  of  non-adherence,  and 

approach  and  separate  the  growth 
from  the  wall  with  the  fingers, 
rather  than  to  attempt  to  dissect 
the  adhesions  apart  in  the  direct 
line  of  approach.  Careful  scrutiny 
of  the  line  of  intestinal  sewing 
should  be  made,  for  evident  reasons, 
and  any  defect  must  be  promptly 
repaired.  Omental  grafting  (Fig. 
888),  to  cover  a  defect,  can  be  prac- 
ticed, and  gauze  packing  around 
the  line  of  junction  should  always, 
be  inserted  and  permitted  to  re- 
main three  or  four  days,  unless  the 
abdominal  wound  be  sooner  closed 
(Fig.  918).  Hie  results  (Butliu)  in 
removal  of  caecum  and  ascending  colon,  of  95  cases,  29  deaths,  20  per  cent 
better  in  females  than  males.  Suture,  end  to  end,  51  cases,  21  deaths ;  suture, 
lateral,  5  cases,  1  death.  Artificial  anus,  secondary  resection,  9  cases,  2  deaths. 
Murphy's  button,  7  cases,  2  deaths.  Senn's  plates,  3  cases,  1  death.  Maun- 
sell's,  Paul's,  and  Mayo-Robson's  method,  each  1.     Paul's  died. 

The  Removal  of  the  Vermiform  Appendix.— The  removal  of  the  vermi- 
form appendix  for  relief  from  manifestations  formerly  regarded  as  due  to 
typhlitis  is  a  modern  procedure  and  the  product  of  the  genius  of  American 
surgeons.  The  diagnosis  of  ap- 
pendicitis and  the  technique  of 
the  operation  for  its  relief  are 
matters  of  such  general  medical 
and  surgical  attainment  now  that 
prompt  and  effective  treatment 
should  be  a  part  of  the  medical 
history  of  every  community. 

The  Anatomical  Points. — The 
appendix  varies  in  its  origin,  di- 
rection, size,  nature  of  the  con- 
tents, etc.,  sufficiently  to  warrant 
a  little  delay  in  order  that  the  sur- 
gical importance  of  these  varia- 
tions can  be  given  consideration. 
In  the  majority  of  instances  the  appendix  arises  from  the  c.Tcum  at  a  point 
about  an  inch  below  the  ileo-coecal  junction  posteriorly.  There  are  two 
good  guides  to  the  location  of  the  base  of  the  appendix,  a  superficial  and  a 
deep  one.     The  former  is  known  as  "  McBurney's  point,"  and  is  located  as 


Fig.  919. — The  caecum  and  appendix,  a.  Fibrous 
band.  h.  "Free"  portion  of  appendix,  c. 
Ileum,    d.  Subperitoneal  portion  of  appendix. 


oi'KKA  rioNs  (»\  vis('i:i:a  (!ONNEcti:i)  wi'iii  i'kimton^um.    709 

near  as  may  bo — about  two  inches  iiitenially — to  the  anterior  superior  spinous 
process  of  the  ilium  and  on  the  imaginary  line  (Fig.  9:i3,  «,  ^)  extending 
between  it  and  the  umbilicus.  It  is  proper  to  say,  however,  that  the  relation 
of  this  point  to  the  anterior  superior  s})inous  process,  when  indicated  on  the 
surface,  will  depend  entirely  on  the  location  of  the  part  of  the  surface  to 
which  the  prc-^sure  is  aj)plied  and  the  direction  of  its  ai)plication.  There- 
fore, some  say  that  it  is  located  midway  between  the  spine  and  the  umbilicus, 
and  others  at  different  situations.  The  latter  guide  is  the  fibrous  band 
(Fig.  019,  a)  that  characterizes  the  caBCum  and  large  intestine,  and  arises  at 
the  base  of  the  appendix.  As  has  been  shown  by  the  author  already,  founded 
on  the  examination  of  one  hundred  and  forty-four  post-mortem  cases,  the 
appendix  extended  inward  in  twenty-four  per  cent,  was  behind  the  caecum 
in  twenty,  and  entered  the  pelvic  cavity  in  fourteen  per  cent  of  the  cases, 
and  in  each  instance  this  position  was  twice  as  frequent  in  the  male  as  in  the 


Fig.  920. — The  caecum  and  appendix  (fa'tal  type),     a.  Fibrous  band.     b.  Base  of  appendix, 

c.  Moso-appendix.     d.  Ileum. 

female,  because  of  the  greater  length  of  the  appendix  of  the  former.  In  the 
remaining  instances  the  directions  were  upward,  behind,  or  to  the  outer  side 
of  the  cfecum,  upward  behind  the  colon,  downward,  or  in  other  directions 
closely  related  to  the  preceding.  But  enough  has  been  stated  already  to 
establish  the  fact  that  the  position  of  the  appendix  varies  greatly,  and 
indeed  the  local  manifestations  of  a  diseased  appendix  depend  much  on 
the  position  it  occupies.  Little  need  be  said  of  the  size  except  as  bearing 
on  its  relation  to  the  contents  and  the  localization  of  the  organ  by  abdomi- 
nal palpation.  In  forty  cases  measured,  irrespective  of  sex,  eighty-nine 
per  cent  were  five  sixteenths  of  an  inch  in  diameter  and  contained  fa?cal 
or  other  foreign  material.  The  remainder  were  of  a  less  diameter  and  con- 
tained less  frequently  foreign  matters.  In  some  instances  we  have  been  able 
to  locate  the  appendix  in  the  living  by  abdominal  palpation  in  the  absence 


YIO 


OPKltATIVH   srilGKKY. 


of  pain  and  tenderness.  However,  when  the  variations  in  location,  direction, 
and  size  of  the  organ  are  noted,  it  is  not  strange  at  all  that  it  is  so  fre- 
quently undetected ;  and,  too,  since  the  increase  in  size  is  in  direct  propor- 
tion to  the  amount  of  abnormal  contents,  should  not,  indeed,  the  advan- 
tages to  be  gained  be  tlioiightfully  compared  with  the  dangers  incurred  by 

manipulation  before  the  at- 
tempt is  made?  In  sixty-seven 
per  cent  of  the  cases  (one  hun- 
dred and  twenty-four)  the  ap- 
pendix contained  abnormal 
material,  which  was  seen  in 
fourteen  per  cent  more  of  the 
male  than  of  the  female  sex. 
The  mesentery  of  the  appendix 
varied  much  in  extent  and 
area.  In  forty  per  cent  half 
or  less  of  the  length  of  the 
appendix  was  surrounded  with 
peritonaeum  {b),  or  "  free,"  as 
the  expression  goes,  and  for 
this  reason  possessed  a  greater 
power  for  evil  when  diseased. 
Cseca  differ  in  their  types  (Fig. 
920).  The  situation  of  the 
right  linea  semilunaris  should 
be  fixed,  not  only  that  it  may 
be  divided  if  need  be,  but  also 
to  prevent,  if  not  desirable, 
entrance  to  the  sheath  of  the 
rectus  muscle.  The  relative  di- 
rection of  the  fibers  of  the  re- 
spective structures  that  overlie 
the  caecum  should  be  carefully 
noted,  also  its  relation  to  con- 
tiguous vascular,  nervous,  and 
other  structures  (Fig.  921),  not 
only  to  enable  one  to  recognize 
the  structures  in  proper  order,  but  also  to  facilitate  an  intelligent  separation 
of  their  fibers  should  circumstances  require  it. 

For  the  purposes  of  operative  treatment  of  appendicitis  five  classes  of 
cases  are  considered,  the  arrangements  of  which  are  suggested  by  the  rela- 
tions noted  to  exist  between  their  respective  histories  and  the  conditions 
revealed  by  operation,  together  with  their  relative  danger  to  life : 

1.  Acute  appendicitis  characterized  by  sudden  perforation  and  diffuse 
septic  peritonitis. 

2.  Subacute  appendicitis  of  insidious  development  usually  complicated 
with  perforation,  attended  with  more  or  less  circumscribed  suppuration,  and 


Fig.  921. — Transverse  section  through  pelvis  at 
the  level  of  anterior  superior  spinous  pro- 
cess and  saero-vertebral  angle.  «.  Dotted 
line,  indicating  periton.Tum.  h.  Transver- 
salis  fascia,  c.  Aponeurosis  of  external  ob- 
lique, d.  Iliac  fascia,  e.  Psoas  parvus.  /. 
Post-peritoneal  connective  tissue,  g.  Anterior 
crural  nerve,  h.  External  iliac  artery.  i. 
Iliac  veins,  j.  Internal  iliac  artery.  A*.  Sacro- 
iliac junction.  These  relations  are  important 
in  estimating  the  influence  of  the  situation  of 
the  appendix  on  the  symptoms,  signs,  and 
coraphcations  in  disease  of  the  organ. 


OPKKATIOXS   ()\    VISCKUA    CONN  Kl   TKl »    WITH     I'KIM  TO.N.KL'M.      TU 

possibly  hv  pliK-hitis,  :il)sci'ss  of  i\w.  liver,  .sul)i»lircni(!  abscess,  abscess  in  tlie 
pelvis,  etc. 

;}.   Acute  apitciuliriiis   with    perforation   and   circiiiuscribcd   suppurative 

peritonitis. 

4.   Recurrent  and  relausinu  ;ii>[t(ii(li(il  is,  with  varying  intervals  of  attack 


Fig.  i)2'2.— Iiistrmiients  employed  in  openition  for  appendicitis. 
a.  Scalpels.  l>.  Uistouries.  c.  Forci pressure,  d.  Curved  and  straight  scissors,  e.  Tliumb 
forceps,  f.  Ncedledioldcr.  h.  Retractors,  i.  Sponge-holder.  /.  Wicking  surrounded 
by  fenestrated  rubber  tissue,  for  drainage,  k:  Rubber  drainage  tube.  /.  Needles, 
sutures,  and  traction  loops,  w.  Gauze  for  drainage,  n.  (Uass  tulics.  for  nnsnig  and 
drainage,  u.  'renaculuin.  p.  Catgut  and  silk  ligatures,  cj.  Steel  i.rolie.  to  deter- 
mine patency  of  lumen  with  caecum,  and  to  cauterize  the  mucous  membrane  of  the 
stump.     Broad  retractors  and  Paquelin's  cautery  arc  often  much  needed. 


712 


OPERATIVE   SURGERY. 


which  unfit  the  patient  for  the  duties  of  life ;  these  cases  not  infrequently 
terminate  fatally. 

5.  Acute  catarrhal  appendicitis  with  or  without  involvement  of  the  walls 
of  the  appendix  and  with  plastic  inflammation. 


nil  i'llW  nU 


Fig.  923. 


Fi(i.  924. 


Pig.  923. — Tlie  superficial  incisions,  a,  *.  Imaginary  line  between  anterior  superior 
spinous  process  and  umbilicus.  b,  c.  Lines  of  incision  in  the  Battle- Kammerer- 
Jalaguier  method,  d.  Vertical  incision,  e.  McBurney  incision.  /.  Hypogastric 
incision,  g.  Vischer's  incision.  Other  incisions  are  omitted  to  avoid  confusion,  but 
some  of  them  will  be  described  in  the  text. 

Fig.  924. — The  deep  incisions  and  their  muscular  and  aponeurotic  relations.  «,  *.  Imag- 
inary line  between  anterior  superior  spinous  process  and  umbilicus,  b',  c .  The 
Battle -Kammerer-Jalaguier  method.  fZ'.  The  vertical  incision  method,  e' .  The 
McBurney  (gridiron)  method.  /'.  The  hypogastric  method,  g' .  Vischer's  method. 
Ileo-colostoiny  shown  at  the  left,     a,  b.  Maydl's  method  of  jejunostomy  (page  T6G). 


The  operative  technique  of  appendicitis  demands  the  application  of  the 
rules  of  asepsis  in  a  most  rigorous  manner.  The  operation  field,  as  well  as 
everything  brought  in  contact  with  the  wound  and  employed  in  the  opera- 
tion itself,  must  be  made  thoroughly  aseptic  with  painstaking  care.  Abun- 
dant hot  saline  solution,  ample  sponges  and  aseptic  cloths,  iodoform  gauze, 
and  drainage  agents  should  be  provided.  Stimulating  agents  for  the  imme- 
diate and  remoter  treatment  of  shock  are  needed.  In  the  absence  of  the  stereo- 
typed operating  table  of  hospital  life,  the  extemporized  one  of  humble  sta- 
tion or  urgent  demand  will  fulfill  adequately  the  necessary  requirements  of 
the  occasion  (Fig.  50).  A  table  allowing  postural  changes  of  the  patient 
may  be  of  advantage  in  the  examination  of  the  pelvic  cavity  to  expose  the 
presence  of  diseased  action  or  products,  but  it  is  not  indispensable. 


OPKKATIOXS    OX    VISCKKA   COW  KC'I'KD    WITH    I'KiaTON.EUM.     713 


77/f  Inrisiofis. — The  jirimiiry  incisions  (Fi^.  9^;5)  Jirc  nuiinly  located  on 
the  right  side  between  the  linoa  seinihinaris  at  the  inner  and  the  iliac  spine 
and  Poupart's  ligament  at  the  outer  limit.  Differently  directed  incisions  are 
advised  in  this  operation  :  the  vertical  and  the  oblique  are  the  ones  usually 
employed.  Kaeh  of  these  incisions  begins  about  an  inch  above  a  line  extend- 
ing from  the  anterior  superior  spine  of  the  ilium  to  the  umbilicus;  each  is 
made  about  three  inches  in  length  at  the  outset  and  is  modified  thereafter  as 
maybe  advisable.  The  oblique  intermuscular  ("gridiron")  dissection  and 
the  oblique  free  division  (page  720)  of  the  tissues  at  substantially  the  same 
location  are  cjuijloyed  ;  the  latter  less  frequently  than  formerly,  because  of 
hernial  sequels  which  happened  in  about  five  per  cent  of  the  cases  (Fig.  924). 
The  vertical  incision  is  made  through  the  outer  margin  of  the  linea  semi- 
lunaris, and  ])referably  involving  the  terminations  of  the  transverse  muscu- 
lar fibers  at  this  situation. 

The  Remarks. — The  careful  union  and  prompt  repair  of  the  divided  ends 
of  the  muscles  and  of  the  separated  borders  of  bundles  of  this  tissue  are  fol- 
lowed by  as  firm  and  often  by  securer  union  than  that  of  divided  aponeurotic 
structure.  The  location,  direction,  and  extent  of  a  primary  incision  should 
be  regulated  much  more  by  the  seat  of  disease  and  the  prospective  utility  of 
the  incision  than  by  a  stereotyped  rule  of  practice.  A  healthy  appendix,  or 
one  but  slightly  diseased  and  non-adherent,  can  readily  be  removed  through 
an  incision  an  inch  or  two  in  length,  but  in  reverse  conditions  the  length  of 
the  opening  should  always  correspond 
with  the  demands  of  safe  practice.  The 
oblique  intramuscular  separation  [e') 
exposes  the  patient  to  the  minimum 
danger  of  hernial  sequels,  the  vertical  {d') 
and  the  free  oblique  to  the  maximum. 
The  modified  methods  of  approach  to  the 
seat  of  disease  will  be  considered  as  the 
conditions  demanding  their  adoption  ap- 
pear. 

The  Treatment  of  the  Appendix. — 
The  appendix  should  always  be  removed 
when  consistent  with  the  welfare  of  the 
patient.  If  adherent,  it  should  be  cau- 
tiously separated  from  its  connections, 
from  the  base  downward  or  apex  up- 
ward, as  convenience  and  care  may  dic- 
tate, observing  that  no  portion  of  it  re- 
mains behind.  Its  mesentery  should  be 
tied  with  catgut  in  one  or  more  sec- 
tions, then  divided  wath  scissors,  and  the 
appendix,  raised  up  along  with  the  wall  of  the  csecum  into  the  wound, 
isolated  by  aseptic  surrouiulings,  and  perhaps  caught  with  forceps  or 
loosely  with  a  ligature,  close  at  the  base  (Fig.  9"25),  should  be  cut  off  about 
half   an   inch   from   its   oriscin   and  a  sleeve  of   serous    membrane   turned 


V^ 


Fio.  025. — Fowler's  treiitinent  of  ap- 
pendix, showing  base  caught  by 
ligature,  distal  ligature  to  prevent 
escape  of  contents,  and  line  indi- 
cating division  of  the  mucous  mem- 
brane. 


714 


OPERATIVE  SURGERY. 


i;p  (Fig.  926).  The  patency  of  the  lumen  of  the  stump  is  then  established 
before  the  ligature  is  applied  by  the  introduction  through  it  into  the 
cfficum  of  a  probe  (Fig.  922,  q).  The  stump  may  be  treated  by  one  of  the 
following  methods : 

a.  By  drawing  the  serous  coat  over  the  ends  of  the  inner  structures  and 
uniting  it  there  with  fine  silk  or  catgut. 

h.  By  suturing  together  the  outer  and  middle  coats  after  removal  of  the 
inner  (mucous)  by  cutting  or  cautery. 

c.  By  depressing  a  short,  flexible  stump  into  the  wall  of  the  caecum  (Fig. 
927)  and  burying  it  there  by  joining  together  with  sutures  the  borders  of  the 
caecal  depression  (Fig.  928). 

d.  By  severing  the  stump  close  to  the  csecum,  inverting  the  borders 
and  uniting  them  as  before  with  sutures. 

e.  By  destroying  the  mucous  lining  of  the  stump  with  cautery,  and  liga- 
turing it  with  catgut  "  within  the  cauter- 
ized area."     After  which  the  end  is  re- 
duced to  small  proportions  by  trimming 
and  cauterization  (McBurney). 

/.  By  first  depositing  around  the 
stump,  near  its  base,  a  purse-string  su- 
ture going  through  the  superficial  tissues 
of  the  cfficum,  leaving  it  untied.  Then 
cut  off  the  appendix  half  an  inch  from 
the  base,  stretch  the  lumen  by  the  intro- 
duction into  it,  and  the  separation  of  the 


Fui.  926.  Fi(i.  927. 

Fig.  926. — Fowler's  treatment  of  appendix,  showing  serous  sleeve  turned  \\\^  and  end  of 

stump  tied. 
Fig.  927. — Fowler's  treatment  of  appendix,  showing  stump  buried  in  wall  of  ca-euni. 

blades,  of  fine  forceps  ;  invaginate  the  stretched  tissues  into  the  caecum  with 
forceps,  and  hold  them  there  while  the  suture  is  being  tied  (Dawbarn). 

g.  By  applying  to  the  base  of  the  appendix,  a  quarter  of  an  inch  from  its 
caecal  origin,  a  provisional  catgut  ligature.     Isolate  the  appendix  with  gauze, 


oi'KUAriu.Ns  ON  vis('i;i:a  coxnectki)  wiTJi  1'i:ritoxj:um.    715 

and  sever  it  beyoiul  the  ligiiture  with  scissors;  cauterize  the  lumen  and  the 
end  of  the  stump,  jind  apply  a  second  catgut  ligature  to  reinforce  the  first 
(McCosh). 

The  liemdrks. — The  adoption  of  any  i)articular  method  of  treatment  of 
the  appendix  is  not  of  as  much  importance  as  is  the  practice  that  eliminates 
from  the  stump  and  its  environments  infecting  agents  and  possibilities.  It 
often  ha{){)eiis,  on  account  of  disease  of  the  appendix 
at  its  origin  or  of  the  wall  of  the  caecum  near  by,  | 
that  the  practice  must  be  made  to  conform  to  the  - 
princi})les  of  safety  rather  than  to  imitation  of  any 
stereotyped  methods. 

In  suppurative  cases,  the  ligature  of  the  appen- 
dix before  or  after  cauterization  of  the  mucous  mem-     Fi<;.  !»2y.— Fowler's  treat- 

u  1  *.  -i.      •  -i.  ca    •       L        (\    ^       ^  lliCTit      of      appoinlix, 

brane  and  extremity  is  quite  suihcient.     Only  dura-  showing  sutuifd  l)or- 

ble  catgut  ligatures  should  be  employed  in  the  *l>'i"^  "f  cxtal  depres- 
infected  cases,  since  silk  ligatures  under  those  condi- 
tions will  invite  and  may  perpetuate  the  infection.  Xot  infrequently  gan- 
grene and  other  destructive  changes  at  the  base  of  the  appendix  will  render 
the  whole  or  part  of  the  structure  unavailable  for  the  purposes  of  repair. 
In  such  cases  as  these  the  utilization  of  the  healthy  parts,  combined  with 
caecal  inversion  and  sewing,  will  answer  the  purpose.  Other  modifications 
of  treatment  of  the  appendix  will  be  remarked  farther  along,  as  circum- 
stances may  require. 

Acute  Appendicitis,  characterized  by  Sudden  Perforation  and  Diffuse 
Septic  Peritonitis. — Through  the  vertical — made  at  the  outer  muscular  bor- 
der (Fig.  0"^3,  d) — or  by  an  oblique  free  division  (page  713)  pass  rajoidly 
down  to  the  peritonaeum.  Arrest  haemorrhage,  thoroughly  cleanse  the  opera- 
tion field  and  incise  the  peritonaeum,  which  will  not  in  these  cases  be  adhe- 
rent to  underlying  structures.  Introduce  traction  sutures  through  the  entire 
thickness  of  both  borders  of  the  wound  and  open  the  wound  wide,  prevent- 
ing at  the  same  time  the  escape  of  distended  intestines  with  the  hand,  or  a 
thin,  f!at  sponge.  Wash  the  field  freely  with  the  hot  saline  solution,  sop  up 
the  fluid  with  gauze,  and  locate  the  fibrous  longitudinal  band  at  the  inner 
aspect  of  the  c«cum  (F'ig.  920) ;  follow  it  downward  carefully  to  the  base 
of  the  appendix,  and  push  aside  the  intestines  and  hold  them  with  the 
fingers  or  gauze  so  that  the  appendix  can  be  located,  increasing  the  exter- 
nal incision,  if  necessary,  enough  to  permit  prompt  and  free  inspection. 
Raise  up  the  appendix,  remove  it  quickly  by  one  of  the  simple  methods, 
using  cautery  if  time  will  permit.  As  the  chief  danger  in  this  class  is  death 
from  sepsis,  which  has  already  involved  more  or  less  of  the  peritoneal  cavity, 
and  is  rapidly  spreading,  unhindered  by  adhesive  limitation,  the  proper 
cleansing  and  draining  of  the  cavity  are  the  desiderata.  The  site  of  the 
appendix  and  the  contiguous  tissues  are  promptly  cleansed  and  fajcal  con- 
cretions removed.  The  examination  is  quickly  though  cautiously  extended 
inward  in  various  directions  in  search  of  collections  of  fluid,  the  pelvic  cavity 
and  intestinal  folds  being  carefully  inspected  in  this  regard.  Small,  fine 
sponges  on  holders,  following  closely  after  a  carefully  advancing  finger,  are 


71(^  OPERATIVE  SURGERY. 

vigilant  agents  of  discovery  and  removal  of  offensive  fluids.  The  variations 
in  the  degree  of  inflammation  of  the  intestine  will  speak  nnerriugly  of  the 
direction  and  vigor  of  the  disease  as  the  examination  progresses.  The  effec- 
tive cleansing  of  the  peritoneal  cavity  (page  G12)  is  very  much  hindered  by 
tiie  intestinal  distention  that  attends  this  class  of  cases ;  in  some,  in  fact,  in 
Avhich  this  manifestation  is  marked,  it  is  very  doubtful  if  even  earnest 
attempts  in  this  line  of  action  meet  with  a  commensurate  reward.  The 
forcing  between  the  folds  of  intestines  of  fluids  that  do  not  promptly 
return  can  but  increase  the  extent  of  the  disease.  Therefore,  we  are  dis- 
posed to  believe  that  eventration  in  joroper  cases  offers  no  less  chance  of 
relief  than  forced  and  ineffective  douching  of  the  abdominal  cavity.  The 
hot  saline  solution  (115°  F.)  is  ponred  freely  into  the  opening,  and  cansed 
to  enter  the  pelvic  cavity  and  pass  among  the  intestinal  folds  by  pushing 
aside  and  separating  the  intestines  with  the  hands.  The  fluid  is  thus  re- 
peatedly introduced  and  caused  to  mingle  freely  with  the  intestines  by  agita- 
tion, with  the  hand  in  the  abdomen  and  in  the  cavity,  and  then  permitted 
to  escape  by  turning  the  patient  on  the  side  until  it  bears  no  gross  evidence 
of  infection.  The  patient  should  then  be  raised  somewhat  to  cause  the  fluid 
to  collect  in  the  pelvic  cavity,  from  which  it  is  carefully  removed  by  lai'ge, 
soft,  aseptic  sponges  successively  introduced,  remembering  that  frequent 
or  too  vigorous  sponging  causes  superficial  traumatism  of  serous  surfaces. 
Careful  inspection  of  intestinal  loops,  aided  by  temporary  removal  of  each, 
and  attended  with  the  wiping  away  of  infecting  agents  therefrom  with  soft 
sponges,  as  well  as  the  absorption  of  vicarious  collections  of  fluid  by  the  same 
agents,  characterizes  the  cleansing  process.  Drainage  is  a  very  necessary 
element  of  treatment  (page  613).  The  pelvic  cavity,  the  planes  beneath  and 
between  the  intestines,  and  especially  the  serous  fossa3  (page  G13)  associated 
with  the  cfecum,  should  be  carefully  drained.  The  glass  drainage  tube  (Fig. 
778)  containing  gauze  is  suitable  for  the  pelvis ;  candle-wicking  incased  in 
perforated  rubber  tissue  may  be  employed  instead  (Fig.  922,  /).  The  latter 
agent  can  be  wisely  employed  between  the  intestinal  folds,  extended  in  all 
necessary  directions,  and  caused  to  escape  at  the  abdominal  opening.  Strips 
of  iodoform  or  of  simple  gauze  can  be  introduced  in  a  similar  manner. 
Finally,  the  previous  location  of  the  appendix  and  the  wound  itself  are 
loosely  filled  with  gauze.  The  fluid  accumulating  in  the  glass  tube  is  with- 
drawn frequently  with  a  small  rubber  tube  connected  with  the  nozzle  of  a 
syringe  arranged  for  the  purpose,  and  kept  in  an  antiseptic  solution  when 
not  in  use.  The  tube  is  removed  early  (page  614  et  seq.),  and  a  strip  of 
gauze  is  usually  left  in  its  place.  The  other  agents  used  for  drainage  are 
removed  as  soon  as  they  have  served  their  jjurpose. 

llie  RemarTcs. — As  much  as  possible  of  the  fluid  that  may  be  in  the 
abdominal  cavity  should  be  caused  to  run  out  through  the  opening  before 
the  saline  solution  is  introduced  for  flushing,  to  prevent  the  dissemination 
that  may  attend  the  act.  A  perforated  rubber  or  glass  tube,  carefully  guided 
by  the  finger,  is  fi-equently  advantageous  in  cleansing  the  culs-de-sac  that 
often  harbor  infection.  The  leaving  behind  in  the  peritoneal  cavity,  in 
these  cases,  of  a  quart  or  so  of  the  saline  solution  is  regarded  as  being 


Ol'llltATlDNS   oX    VISCllKA    CoNXKCl'i:!)    Willi    I'l  :KIT(JN  JllM.      717 

beneficnal  (jia^o  (Ilo).  Slionld  vomitiiif^  occur,  ciiiilion  is  required  to  prevent 
the  escjijio  of  intestine  tliruugli  the  dniinage  opening. 

llie  licsiiUs. —  In  this  class  of  cases  the  operative  results  are  unfavorable, 
and  it  is  luiexpected  indeed  if  recovery  takes  place  when  the  peritonitis  has 
become  general.  The  fact  that  au  incalculable  degree  of  involvement  of  the 
serous  membrane  is  a  part  of  the  earliest  surgical  history  makes  the  prog- 
nosis unfavorable  at  the  outset,  and  emphasizes  the  advisability  of  early 
operative  procedure  when  possible.  The  outcome  is  no  doubt  better  than 
formerly,  because  of  the  imi)roved  knowledge  of  their  nature  and  of  the  salu- 
tary inlluence  of  free  ilushing  of  the  peritoneal  cavity  with  hot  saline  fluid 
and  of  etiicient  drainage.  However,  the  difference  in  the  results  reported 
by  equally  competent  observers  suggests  strongly  the  fact  of  a  corresponding 
difference  of  nnderstanding  regarding  the  diagnosis  of  the  condition.  Tlie 
rates  reported  vary  from  total  demise  to  thirty-three  and  a  third  per  cent 
recovery. 

Subacute  Appendicitis  of  Insidious  Development,  usually  complicated  with 
Perforation,  attended  with  more  or  less  Circumscribed  Suppuration,  and  possi- 
bly by  Phlebitis,  Abscess  of  the  Liver,  Subphrenic  Abscess,  Abscess  in  the  Pel- 
vis, Etc. —  In  the  second  class  the  disease  is  exposed  through  a  vertical  or  modi- 
fied incision  (page  728),  as  circumstances  require,  and  the  tissues  are  divided 
down  to  the  peritonanim.  If  a  pronounced  degree  of  suppuration  have  taken 
place  beneath  the  line  of  incision,  and  the  peritonaeum  there  have  become 
adherent  beneath,  the  deep  tissue  will  be  cedematous,  the  fatty  portion  pre- 
senting a  yellow  aspect.  If  fluctuation  be  felt  now,  the  solution  of  the  problem 
is  easy.  However,  the  elasticity  of  an  adherent  intestine  should  not  be  mis- 
taken for  that  of  pus,  and  the  remaining  tissues  must  be  cautiously  divided 
in  any  event.  If  the  deeper  tissues  be  but  little  changed,  or  not  at  all,  in 
this  regard,  a  deepening  of  the  incision  will  quite  surely  involve  the  general 
peritoneal  cavity.  Therefore,  every  precaution  against  the  spread  of  infec- 
tion, by  repression  of  the  intestines  and  packing  of  the  borders  with  iodo- 
form gauze,  should  immediately  follow  this  advancing  step.  In  the  former 
instance,  the  use  of  a  hypodermic  syringe,  sharp  probe,  grooved  director, 
point  of  the  knife  or  closed  scissors  can  be  used  to  gain  an  entrance  by  pene- 
tration or  friction  into  the  thin-walled  cavity.  Wipe  away  promptly  the  pus 
as  it  appears,  and  enlarge  the  opening  by  stretching  until  the  finger  can  be 
introduced  into  the  abscess,  by  means  of  which  the  relation  of  the  abscess 
wall  to  the  abdomen  in  front  can  be  safely  estimated.  The  opening  is  then 
increased  in  length  upward  or  downward,  as  the  intestinal  relations  and  the 
pus  collections  suggest.  Draw  the  lips  of  the  wound  apart  with  traction 
sutures,  and  with  the  finger  examine  the  w^alls  of  the  abscess  for  openings  or 
weak  points,  and  the  bottom  for  the  presence  of  foreign  bodies.  If  the 
abscess  be  thin-walled  at  points,  or  the  wall  be  torn  in  the  manipulation, 
it  should  be  wiped  clean  and  repaired  at  once  by  a  careful  packing  with 
gauze.  Eiuse  the  cavity  with  the  hot  saline  solution  poured  from  a  pitcher 
but  little  elevated,  the  stream  being  directed  or  modified  in  force  by  the 
interposition  of  the  hand ;  separate  the  deeper  walls  with  the  fingers,  and 
Avipe  away  with  small,  soft  sponges  the  fluid  remaiiiinL;-  in  tlie  cavity.    Locate 


718  OPEKATIVE   SURGERY. 

and  remove  the  appendix,  unless  its  removal  may  rupture  the  limiting  wall 
of  the  abscess  at  its  peritoneal  aspect  and  cause  extended  infection.  And  then 
the  appendix  can  often  be  divided  at  the  base,  the  stump  treated  as  in  other 
suppurative  cases,  and  what  is  practicable  removed,  the  remainder  slit  up  and 
perhajjs  curetted,  leaving  the  intramural  portion  to  the  care  of  Xature.  In 
this  class  of  cases,  especially,  the  base  of  the  appendix  should  be  located 
first  in  all  instances,  and  its  course  in  the  abdomen  carefully  followed,  for 
along  it  not  infrequently  the  purulent  canal  passes  up  behind  the  ascending 
colon  to  the  liver,  or  into  the  pelvis,  etc.,  involving  large  vessels  and  estab- 
lishing isolated  pus  collections.  The  diversity  of  the  direction  of  the  appen- 
dix within  the  abdomen  should  be  considered  in  the  exploration  of  these  cases 
(page  ?09).  The  external  wound  must  be  enlarged,  and  the  walls  of  the  puru- 
lent canals  and  collections  separated,  carefully  examined,  and,  when  necessary, 
repaired  with  iodoform  gauze  and  drained,  as  the  examination  progresses. 
If  the  appendix  extend  toward  the  pelvis,  it  may  enter  that  cavity  and  per- 
foration occur  at  the  intrapelvic  part  of  the  organ,  causing  pelvic  abscess. 
The  careful  exploration  of  the  pelvic  cavity,  with  one  or  more  fingers  intro- 
duced through  the  vagina  or  rectum  will,  in  these  cases,  often  elicit  the  pres- 
ence of  tumor  there,  attended  with  pain  and  tenderness.  These  pus  collec- 
tions can  be  reached  from  the  original  incision  by  careful  separation  of  the 
intestines  with  the  fingers  in  the  course  of  the  appendix,  accompanied  with 
simultaneous  tunneling  of  the  canal  with  gauze.  The  not  infrequent  prac- 
tice of  blindly  fumbling  among  the  intestines  for  pus  with  the  finger,  with- 
out gauze  fortification,  is  as  dangerous  as  indelicate,  sometimes  causing 
perforation  of  the  intestine,  and  always  heightening  the  danger  to  the 
patient  from  general  peritoneal  infection.  Xot  infrequently  pelvic  abscesses 
due  to  appendicitis  are  opened  through  the  vagina  or  rectum,  especially  in 
depressed  cases  and  those  in  which  the  uncertainty  as  to  surgical  technique 
makes  this  the  safer  procedure  of  the  two.  The  appendix  is  rarely  indeed 
situated  extraperitoneally  and  upward  behind  the  ascending  colon  (two  per 
cent),  as  may  happen  in  this  class.  Under  these  circumstances,  with  high 
perforation  and  cellular  infiammation,  the  abscess  may  require  oj^ening  above 
the  crest  of  the  ilium  (Fig.  923,  g). 

The  BemarTcs. — If  abscess  be  found  in  the  pelvis  it  is  wiser  to  approach 
it  tlirough  an  incision  in  the  median  line,  or  through  a  modified  incision  (page 
723),  than  to  practice  inadequate,  harmful,  and  prolonged  manipulative  efforts 
through  the  primary  incision.  The  author  has  observed  three  cases  of  this 
class  complicated  respectively  with  subphrenic  abscess,  abscess  of  the  deep 
tissues  of  the  body,  and  high  perforation  of  the  colon.  Presumptively  the 
appendix  extended  upward,  beneath  the  peritonaeum  and  behind  the  colon 
in  each  instance.  It  sometimes  happens  that  an  appendix  of  abnormal 
length  and  unusual  location  causes  in  distant  parts  of  the  abdomen  symp- 
toms of  an  acute  or  subacute  nature.  For  these  reasons  appendicitis  at  the 
left  side  is  not  unheard  of,  and  should  therefore  be  regarded  possible  with- 
out transposition  of  viscera. 

Tlie  Results. — In  this  class  of  cases  the  insidious  development  in  numer- 
ous instances  and  the  consequent  uncertainty  of  diagnosis,  the  latter  depend- 


(»im;i;.\'I'i<».\'s  on  vis('i;i;.\  coNNKcrKi)  with   i'kim  tonjum.    7i«» 

ent  nul  iiifrucjiu'iilly  on  tlio  umisuul  li-iiglh  uiul  direction  of  the  appendix, 
are  attended  with  sucli  doubt  and  delay  in  proper  treatment  as  to  deprive 
the  patient  of  the  sahitary  Ijeiu-lUs  of  operative  aetion.  Especially  is  this 
true  when  hepatic  or  venous  complications  ensue.  Fortunately,  however, 
these  cases  are  comparatively  i-arc. 

'J'he  outcome  of  appendicitis  is  less  favorable  when  its  manifestations  are 
located  in  unusual  and  out-of-the-way  ])laces — those  which  blind  diagnostic 
acumen  and  hinder  proper  practice.  For  these  reasons  only  the  final  results 
in  cases  with  pelvic  involvement  arc  often  less  favorable  than  those  of  a  simi- 
lar character  located  nearer  to  hand. 

Acute  Appendicitis  with  Perforation  and  Circumscribed  Suppurative  Peri- 
tonitis.—  In  the  third  class  the  vertical  or  obliijue  incisions  can  be  made  (l*  ig. 
923).  As  a  general  proposition  (page  713),  best  repeated  in  connection  with 
this  class  of  cases  because  of  their  frequency,  the  incision  that  affords  the  best 
opportunity  for  ex])loration  and  drainage  and  avoidance  of  peritoneal  infec- 
tion, with  the  least  liability  thereafter  to  parietal  infirmity,  should  be  adopted. 
Therefore,  tumors  located  near  the  median  line  should  be  incised  at  their 
center,  either  through  the  ordinary  or  the  modified  vertical  incision;  those 
nearer  the  crest  of  the  ilium  and  along  Poupart's  ligament  at  the  external 
aspect  (Fig.  923,/).  Little  can  be  said  regarding  the  treatment  of  abscess 
in  this  class  not  exj^ressed  already  in  the  description  of  the  approach  to,  and 
treatment  of  those  of  the  preceding  class.  Here,  as  there,  the  conditions  of 
the  deep  tissues  of  the  abdominal  wall  indicate  their  relation  to  suppuration, 
and  suggest  like  means  for  the  avoidance  of  infection.  The  appendix  is 
ligatured  with  catgut  after  division  and  cauterization  of  the  mucous  mem- 
brane. In  some  instances  the  appendix  is  missing  entirely,  or  sloughing 
shreddy  remnants  only  attest  its  past  existence.  The  cavity  is  cleansed  by 
■wiping  with  soft  sponges,  aided  by  gentle  flushing  with  the  hot  saline  solu- 
tion, or  a  solution  of  jieroxide  of  hydrogen.  Any  defects  in  the  lymph 
environment  that  were  present  at  the  outset,  or  that  occurred  during  the 
cleansing,  must  be  repaired  at  once  with  iodoform  gauze.  Finally,  the 
wound  is  packed  lightly  with  iodoform  gauze,  and  the  whole  overlaid  with 
sterilized  or  bichloride  gauze  held  in  place  by  an  abdominal  binder.  The 
wound  is  usually  redressed  at  the  end  of  forty-eight  hours.  Still,  an  earlier 
period  may  be  necessary  or  a  later  one  suffice,  depending  on  the  character 
and  extent  of  the  wound  and  the  local  and  constitutional  manifestations 
of  infection.  Visible  soiling  of  the  dressings  calls  for  their  prompt  re- 
moval. The  wiping  out  of  the  wound  with  soft  sponges  or  pieces  of  gauze 
supplemented  with  peroxide  of  hydrogen,  cleansing  of  wound  recesses, 
and  loose  filling  with  gauze,  aided  by  a  constantly  increasing  tension 
of  the  binder  to  limit  the  extent  of  cicatrization,  characterizes  the  local 
treatment. 

The  Remarks. — These  cases  are  of  comparatively  common  occurrence,  and 
usually  the  surgical  technique  can  be  readily  carried  into  effect.  The  deep 
incision  into  the  abscess  differs  but  little  from  that  of  common  abscesses 
elsewhere  in  the  body,  except  when  peritoneal  adhesion  in  front  is  in  doubt ; 
then,  careful  approach  is  requisite,  and  cautious  packing  needed  if  adhesions 


720  OPERATIVE   SURGERY. 

be  absent,  to  avoid  further  infection.  The  practice  relating  to  the  removal 
and  treatment  of  the  appendix  in  other  cases  is  applicable  to  this. 

Tlie  Results. — The  operative  prognosis  is  good,  ])rovided  adhesion  between 
the  visceral  and  parietal  peritoneum  has  taken  place,  or  the  spread  of  infection 
is  prevented  by  suitable  gauze  packing  in  the  absence  of  adhesion  before  the 
pus  is  liberated.  The  effort  to  remove  the  appendix  when  it  is  imbedded  in 
the  limiting  wall  of  the  abscess  often  provokes  extension  of  the  disease  with- 
out offering  a  commensurate  advantage  to  the  patient  (page  718).  Determined 
efforts  of  this  character  should  not  be  made  except  for  better  reasons  than  have 
yet  come  to  the  notice  of  the  author.  Enucleation  from  its  serous  covering 
is  sometimes  practiced  in  these  cases.  The  reported  mortality  operations  in 
acute  cases  are  misleading,  as  it  rarely  happens  that  the  important  influences 
contributing  to  an  unfavorable  result  appear  in  the  statements.  However, 
the  rate  in  acute  cases  of  all  classes  is  about  twenty  per  cent. 

Recurrent  and  Relapsing  Appendicitis,  with  Varying  Intervals  of  At- 
tacks which  unfit  the  Patient  for  the  Duties  of  Life ;  these  Cases  not  infre- 
quently terminate  fatally. — The  cases  of  this  class  are  comparatively  frequent 
indeed,  and  their  relatively  benign  character  invites  prompt  action  which 
affords  safe  relief  from  established  or  prospective  danger.  The  appendix 
may  be  either  entirely  free  or  more  or  less  adherent,  and  sometimes  asso- 
ciated with  limited  old  suppurative  changes.  The  parietal  peritongeum  is 
rarely  adherent  to  the  subjacent  parts,  therefore,  its  division  trespasses  at 
once  on  the  general  peritoneal  territory.  Two  methods  of  approach  are  prac- 
ticed in  these  cases:  one  the  ordinary  (free  incision),  the  other  the  "grid- 
iron" method  (Figs.  923  and  1)24,  e  and  e').  In  the  former,  the  respective 
tissues  are  divided  along  the  line  of  an  oblique  incision  carefully  down  to  the 
peritonaeum  which  is  cautiously  severed,  after  which  the  caecum  is  exposed, 
and  the  fibrous  bands  are  noted  and  followed  down  to  the  base  of  the  appen- 
dix, which  with  the  finger  is  drawn  gently  into  the  wound  along  with  the 
anterior  surface  of  the  caecum,  carefully  examined  to  note  its  entirety,  isolated 
with  aseptic  gauze,  cut  off,  and  treated  according  to  the  method  approved  by 
the  operator.  If  the  appendix  be  adherent  or  involved  in  old  inflammatory 
processes,  as  indicated  by  examination  with  the  fingers,  the  organ  is  carefully 
exposed  and  the  general  peritoneal  cavity  shut  out  by  packing  the  borders 
gently  with  gauze.  The  appendix  is  then  cautiously  disconnected  from  its 
adhesive  environments — carefully  noting  that  no  portion  remains  behind — 
raised  up,  isolated,  and  removed.  In  both  instances  the  operation  field  is 
cleansed  with  the  hot  saline  solution,  and  the  wound  closed  in  those  cases 
that  present  no  evidences  of  present  or  prospective  infection.  In  the  others, 
the  previous  location  of  the  appendix  and  the  wound  itself  are  packed  loosely 
with  gauze,  as  in  the  cases  of  established  infection.  If  the  two  layers  of 
peritonaeum  should  happen  to  be  adherent,  the  main  caution  consists  in 
gaining  the  site  of  the  appendix  without  entering  the  canal  of  an  interposed 
intestine.  However,  if  the  tissues  in  turn  be  accounted  for  as  divided,  and 
the  relation  of  the  tissues  that  immediately  underlie  the  transversalis  mus- 
cle be  noted,  and  the  advance  be  made  slowly  through  the  tissues  by  friction 
severance,  no  pronounced  involvement   will  happen.      If  the  intestine  be 


OlM'lKA'I'loN'S   ON    \1SCI:K'A    CONNECTKI)    WITH    IMllil'I'i  ».\  Jll'.M.     -J-^l 

opt'iKMl,  the  iiK'isiuu  .shuiiUl  be  elused  ;iL  uiice  by  sewing  uiul  the  operation 
contiiiiieil. 

77/t'  h'cDKir/is. — The  intervals  of  (|uiet  of  recurrent  cases,  and  the  ])arox- 
ysniul  nuiuifestations  of  the  rehi[)sing,  constitute  signilicant  ciilTerences  in 
these  kinds  of  appendicitis.  Althougii  neither  of  them  is  as  dangerous  as  is 
a  jiriinary  acute  attack,  still,  either  should  be  regarded  important,  as  it  may 
l)roinj>tly  prove  fatal.  A  second  attack  occurs  in  about  twenty-one  per  cent 
of  acute  cases.     This  class  of  cases  is  often  of  a  catarrhal  nature. 

The  Jief<i<lfs. — In  the  fourth  class  the  prognosis  of  operation  during  the 
attack  is  much  better  than  in  acute  appendicitis.  If  performed  in  the  inter- 
val of  the  attacks  the  death  rate  is  scarcely  two  per  cent.  In  fact,  the 
operation  at  this  time  exposes  the  patient  to  less  danger  than  does  the  pres- 
ence in  the  abdomen  of  the  diseased  appendix.  The  "  gridiron  "  plan  is 
especially  ai)j)lieable  to  these  cases,  since  the  conllnement  in  bed  and  hernial 
sequels  are  reduced  to  a  minimum.  It  should  be  remembered,  however,  that 
secondary  attacks  may  expose  the  patient  to  as  great,  and  even  greater  dan- 
ger than  did  the  primary  acute  one. 

T/ie  Gridiron  Method  (McBurney). — The  gridiron  method  is  indeed  a 
commendable  plan  of  action  in  those  cases  which  admit  of  immediate  clo- 
sure of  the  abdominal  wound.  It  is  beneficent  in  the  prevention  of  the 
hernial  sequels  following  other  common  methods  of  entrance  that  too  often 
plague  the  patient  and  vex  the  surgeon.  The  primary  incision  (Figs.  92.'^ 
and  924,  e  and  e')  is  made  along  the  oblique  line  down  to  the  aponeurosis  of 
the  external  oblique  muscle,  the  fibers  of  which  are  separated  in  the  line  of 
their  course  to  the  proper  extent ;  each  succeeding  layer  of  tissue,  as  it  appears 
after  division  of  the  intermuscular  planes  of  fascia,  is  treated  in  the  same 
manner  until  the  fascife  are  reached.  The  fascias  and  the  peritoneum  are 
divided  independently  in  the  line  of  the  separated  fibers  of  the  transversalis 
muscle,  the  appendix  is  located,  raised  upward  into  the  wound,  and  treated 
as  non-infective.  The  borders  of  the  respective  tissues  of  the  wound  are 
united  to  each  other  with  catgut  in  the  reverse  order  of  separation.  Super- 
ficial drainage  with  a  few  strands  of  catgut  or  a  similar  agent  is  sometimes, 
employed.  The  wound  is  dressed  in  the  usual  manner,  and  the  patient  kept 
quiet  for  twelve  to  fourteen  days.  Owing  to  the  ditferent  directions  of  the 
lines  of  separation  of  the  tissues,  not  less  than  four  retractors  or  retraction 
sutures  are  essential  to  the  proper  exjiosure  of  the  underlying  structures. 

7'he  Remarks. — This  method  of  practice  is  best  adapted  to  non-suppura- 
tive  cases  and  those  in  which  the  area  of  diseased  action  is  of  a  limited 
extent.  However,  many  surgeons  employ  this  plan  in  suppurative  cases, 
especially  in  those  of  limited  extent,  in  order  to  gain  the  benefits  for  the 
patient  of  the  greater  strength  from  uncut  tissues  at  the  seat  of  the  opening 
when  healing  ensues.  If  the  magnitude  of  the  disease  be  large,  or  the 
appendix  be  of  uncommon  length  or  in  an  unusual  position,  the  opening  is- 
often  of  inadequate  size  for  the  purposes  of  safe  and  thorough  practice. 
Under  these  circumstances  its  extent  may  be  increased  by  stretching  with 
retractors  and  by  suitable  division  in  the  requisite  directions  of  the  restrict- 
ing tissues  (page  723).     It  is  proper  to  say  at  this  time,  we  think,  that  the 


722  OPERATIVE   SURGERY. 

rule  of  action  relating  to  the  extent  of  incisions  and  their  relation  to  proper 
observation  and  manipulation  of  both  diseased  and  healthy  structures  (page 
37)  applies  in  abdominal  surgery  with  greater  force,  if  possible,  than  to 
operations  elsewhere  on  the  body. 

The  Results. — Inasmuch  as  this  method  of  procedure  is  especially  appli- 
cable to  chronic  cases  and  to  interval  operations,  the  death  rate,  though 
modified,  of  course,  by  the  experience  and  skill  of  the  operator,  is  exceed- 
ingly small,  varying  from  nil  to  four  or  five  per  cent. 

Acute  Catarrhal  Appendicitis  with  or  without  Involvement  of  the  Wall 
of  the  Appendix  and  with  Plastic  Exudation.— 'JMie  fifth  class  of  cases, 
especially  those  characterized  by  extensive  fibrinous  exudation,  are  often 
attended  with  unique  clinical  expressions  and  an  astonishing  amount  of 
fibrinous  deposit.  They  are  temporarily  regarded,  not  infrequently,  as  sar- 
coma of  the  c<'¥cum.  Either  the  vertical  or  oblique  incision  can  be  em- 
ployed in  this  class  of  cases.  If  the  tumor  be  not  large,  the  "gridiron" 
plan  of  action  may  be  adopted.  In  the  instance  of  a  large  deposit,  the  vis- 
ceral and  parietal  layers  of  the  peritonaeum  will  be  adherent  to  each  other, 
and  thus  shut  off  at  once  the  general  peritoneal  cavity  from  the  line  of 
incision.  If  the  amount  of  exudate  be  small  this  adhesion  will  not  hap- 
pen, and  the  intestines  must  be  pushed  aside  and  held  there  with  gauze  as 
soon  as  they  appear  in  the  wound.  The  search  for  the  appendix  in  the 
fibrinous  mass  should  be  conducted  with  care  to  avoid  injury  of  hidden 
tissues.  If  the  exudate  does  not  involve  the  c£ecum,  or  can  be  separated  from 
it,  the  base  of  the  appendix  can  be  exposed  through  the  guidance  of  the 
fibrous  band  leading  to  it,  and,  finally,  the  entire  organ  can  be  enucleated 
from  its  firm  environment,  noting  carefully  that  no  part  of  it  remains  behind 
to  breed  infectious  jorocesses.  If  the  new  tissue  can  not  be  separated  from 
the  wall  of  the  ctecum  without  endangering  the  integrity  of  the  structure, 
the  deposit  should  be  carefully  pried  open  in  the  long  axis  with  the  handle 
of  a  scalpel,  beginning  at  the  point  of  established  origin  of  the  appendix. 
The  appendix  is  then  carefully  and  completely  removed,  the  stump  treated 
according  to  the  nature  of  the  case,  and  the  wound  closed  if  the  presence  in 
it  of  infective  agents  be  not  suspected.  If  infection  have  been  present,  the 
wound  in  the  abdominal  wall  should  be  shortened  as  much  as  possible  with 
sutures,  the  remaining  wound  cavity  having  first  been  packed  lightly  with 
gauze  to  the  bottom.  The  fibrinous  induration  disappears  rapidly  and  com- 
pletely after  the  removal  of  the  appendix. 

The  Remarks. — Appendicitis  of  this  nature,  while  comparatively  unusual, 
happens  sufficiently  often  to  frequently  perplex  the  medical  attendant  regard- 
ing its  true  nature.  In  more  than  one  instance  the  tumor  on  exposure  has 
been  mistaken  for  sarcoma  of  the  caecum,  and  the  caecum  removed  by  com- 
petent surgeons.  The  writer  recalls  a  somewhat  recent  case  of  this  kind 
in  his  own  practice,  in  which,  owing  to  the  large  size  of  the  tumor,  the 
presence  of  extensive  mesenteric  glandular  involvement,  the  absence  of 
any  local  evidence  of  peritonitis,  the  feeble  state  of  the  patient,  and  the 
indefiniteness  of  the  history  of  the  case,  inoperable  sarcoma  of  the  csecum 
was  diagnosticated.      The  abdominal  incision  was  closed,  and  the  patient 


OPERATIONS   OX    VISCKIt.V   COXNKOTED    WITH    PKRITONiEUM.     793 

nijido  ii  i)ri)iii})t  and  coinpU^to  recovery  aiul  is  vigorous  iind  healthy  at  tlie 
present  time. 

The  Results. — The  results  from  removal  of  the  a})pendix  are  excellent, 
and  none  other  than  a  favorahle  outcome  need  be  expected.  Raj)id  final 
absorption  of  the  plastic  material  follows,  and  in  fact  may  follow  without 
removal  of  the  appendix,  but  is  likely  soon  apjain  to  return. 

The  Removal  of  the  Appendix  during  the  Interval. — In  1888  Treves 
removed  the  appendix  dui'ing  the  interval  in  a  case  of  rela{)sing  ajipendicitis. 
Since  that  time  tiie  wisdom  of  the  plan  has  become  well  recognized  by  the 
profession,  and  is  now  being  quite  generally  practiced.  The  exact  period  of 
time  after  an  attack  before  operative  interference  is  advisai)le  can  not  be  defi- 
nitely stated,  because  of  the  variations  in  the  degree  of  the  infliction  and  in 
the  powers  of  recovery.  Therefore  each  case  should  be  decided  upon  its  own 
merits,  remembering  that  the  completer  the  recovery  the  less  is  the  danger, 
and  consequently  the  simpler  and  safer  is  the  execution.  But  since  the 
removal,  after  practical  subsidence  of  the  manifestations  of  the  attack,  is 
safer  for  the  patient  than  is  the  retention  of  a  rebellious  appendix,  the  opera- 
tion should  be  performed,  if  jjossible,  before  the  appearance  of  another 
attack.  An  interval  of  two  or  three  weeks  may  be  regarded  as  suitable  in 
the  majority  of  cases. 

The  Results. — The  results  of  operation  at  this  period  are  almost  uniformly 
successful,  it  being  infrequent,  indeed,  that  death  occurs  therefrom  in  the 
practice  of  experienced  surgery. 

The  Modified  Incisions. — Modification  of  the  standard  incisions  of  the 
abdomen  are  advised  for  the  purpose  of  meeting  the  demands  of  well-under- 
stood and  of  unanticipated  conditions  that  present  during  the  course  of  the 
operation.  The  gridiron  method  (Fig.  924)  is  ideal  when  the  extent  of  the 
disease  admits  of  proper  treatment.  But  when  for  any  reason  it  becomes 
necessary  to  enlarge  the  opening  by  traction  or  free  division  to  meet  the 
requirements  of  proper  technique,  the  muscular  structures  especially  often 
suffer  in  an  objectionable  degree.  In  such  cases  additional  room  can  be 
gained  by  division  upward  along  the  outer  border  of  the  rectus  muscle 
(Stimson)  of  the  denser  tissues  which  are  united  afterward  by  sewing. 

The  transverse  division  of  the  aponeurosis  of  the  external  oblique  and  the 
superimposed  tissues  from  a  point  located  half  an  inch  inside  of  the  anterior 
superior  spine  of  the  ilium  to  the  outer  border  of  the  rectus  muscle  is  said 
(Elliot)  to  afford  more  room  in  this  method  than  does  the  oblique  division 
of  these  structures.  Weir  gains  the  needed  room  by  tearing  the  "  denuded 
fascia  "  of  the  external  oblique  from  the  sheath  of  the  rectus  to  near  its  inner 
border.  He  then  divides  the  anterior  layer  of  the  sheath  transversely  to  the 
inner  border,  in  the  line  of  the  muscular  separation,  draws  the  rectus  muscle 
inward,  ligatures  the  epigastric  vessels  as  they  appear  in  the  sheath,  cuts  the 
posterior  tissue  of  the  sheath  and  the  peritonaeum  in  a  line  coi'responding  to 
the  division  of  the  anterior  layer.  When  the  borders  of  the  wound  are  drawn 
asunder  the  pelvic  cavity  can  be  freely  examined.  The  tissues  of  the  sup- 
plementary incision  are  repaired  in  the  reverse  of  the  order  of  division.  In 
other  respects  the  wound  is  treated  as  heretofore.      This  measure  affords 


724 


OPERATIVE  SUliGERY. 


ample  room,  with  easy  and  secure  repair,  and  is  a  valuable  adjuvant  of  the 
intermuscular  separation  method. 

At  about  the  same  time  JUtttle,  Kammerer,  and  Jalaguier  each  independ- 
ently proposed  a  novel  method  of  approach  to  the  appendix  through  the 
sheath  of  the  rectus  in  relapsing  cases.  The  anterior  walls  of  the  sheath  and 
the  superimposed  structures  are  divided  vertically  at  the  outer  border  of  the 
rectus  muscle  (Figs.  9:^3  and  924)  ;  the  tissues  at  the  inner  border  of  the 

incision,  including  the  rectus  muscle,  are  drawn 
inward  with  blunt  retractors  (Fig.  929),  thus  ex- 
posing the  posterior  wall  of  the  sheath  and  the 
semilunar  fold  of  Douglas ;  through  the  posterior 
wall  of  the  sheath,  within  half  an  inch  of  the 
outer  limit  (c"),  a  vertical  incision  parallel  with  the 
preceding  one  is  made  into  the  peritoneal  cavity ; 
the  borders  of  this  incision  are  drawn  apart,  the 
intestines  pushed  aside,  and  the  appendix  is  ex- 
posed and  removed.  The  wound  is  closed  in  the 
following  manner :  The  divided  borders  of  the 
peritonaeum,  of  the  fascia,  and  of  the  posterior  wall 
of  the  sheath  are  united  by  a  single  row  of  contin- 
uous or  interrupted  catgut  sutures.  The  rectus 
muscle  is  then  permitted  to  fall  into  place  and  the 
borders  of  the  anterior  layer  of  the  sheath  and 
oblique  aponeurosis  are  joined,  as  in  the  preceding 
instance.  Finally,  the  superficial  tissues  of  the 
wound  are  united  with  catgut  or  silkworm-gut 
sutures. 

The  Remarks. — By  this  method  of  practice  the 
lines  of  union  of  the  divided  tissues  are  fortified  by  the  presence  and  func- 
tion of  the  unimpaired  rectus  muscle  and  the  liability  of  the  occurrence  of 
hernia  is  correspondingly  lessened.  However,  the  degree  of  exposure  to 
injury  of  the  nerves  and  the  epigastric  vessels,  and  the  somewhat  limited 
application  of  the  method,  together  with  the  disadvantages  incident  to  the 
possible  needs  of  drainage,  counsel  the  exercise  of  wise  forethought  in  its 
selection.     This  form  of  incision  is  well  adapted  to  children. 

In  those  cases  of  ajjjjendicitis  exhibiting  evidences  of  abscess  above  the 
crest  of  the  ilium,  always  suggestive  of  the  presence  of  a  diseased  appendix 
behind  or  to  the  outer  side  of  ciecum  and  colon,  an  iliac  or  lumbo-iliac 
(Grinda)  incision  may  be  utilized.  In  such  cases  drainage  through  the  loin 
should  be  practiced,  even  in  the  event  of  the  employment  of  a  standard 
incision.  The  great  thickness  of  the  abdominal  wall  at  the  loin,  and  the 
strong  tendency  of  the  opening  to  close,  calls  for  the  introduction  of  a  large- 
sized  firm-walled  rubber  drainage  tube. 

Vischer^s  incision  is  eminently  practical  in  these  cases.  The  external 
oblique  muscle  is  exposed  through  a  curved  incision  carried  an  inch  above 
the  crest  of  the  ilium  (Fig.  933,  g).  If  additional  room  is  needed,  the  in- 
cision can  be  extended  downward  to  and  along  Poupart's  ligament.     The 


Fig.  929.— Battle-Kaimner- 
ei'-Jalagiiier  metliod.  a. 
Posterior  layer  of  sheath 
of  rectus,  b.  Indicat- 
ing line  of  superficial  ex- 
ternal incision  (b  and  b' , 
P'igs.  928  and  924).  c". 
Line  of  incision  through 
posterior  sheath  of  rec- 
tus, d.  Semilunar  fold 
of  Douglas. 


Ul'KUATlo.NS   ON    VlSt'KKA   CUNNECrKD    WITH    I'lllMTOX .HUM.     725 

fibers  of  the  extt'rnul  oblique  are  separated  (I'Mg.  'J;M, //'),  also  those  of  the 
suceeeiiing  imiscles  down  to  the  fa.scia,  which,  along  with  the  peritoiKt'uni, 
are  dividrd  vertically,  thus  promptly  rcncliiii!^'  the  outer  aspects  of  the  colon 
and  ca'cuni.  Thron^li  tliis  opi'uini^  the  pus  will  escape,  and  the  apj)endix 
can  be  removed  nml  ih[)ciulent  draiiuige  provided.  The  danger  of  hernial 
se(pu'ls  is  not  signilicant. 

Mi'ijcr  atlvocates  an  incision  which  he  dciioniiiiatcs  "the  hockey-stick  in- 
cision." This  incision  conuncnces  at  a  point  hall"  an  inch  above  tlie  iiiia,L:i- 
nary  line  (Kig.  ^'l'.),  ^/,^(.),  and  at  the  junction  of  the  outer  with  tlie  inner 
three  fourths,  passes  oblicpu'ly  downward  and  inward  to  a  point  over  the 
femoral  artery,  and  about  three  quarters  of  an  inch  above  Poupart's  ligament. 
The  tissues  are  treated  as  in  the  intermuscular  method,  and  the  abdomen  is 
opened,  when,  if  additional  room  is  needed,  the  incision  can  be  extended 
upward  and  inward,  or  curved  directly  inward  to  a  horizontal  jilane,  as  cir- 
cumstances require,  thus  forming  the  "  hockey-stick  "  outline  (Fig.  903). 

lite  Remarks. — Ordinarily  the  horizontal  limit  of  the  incision  ends  at 
the  outer  border  of  the  rectus,  but,  if  additional  room  is  required  at  this 
aspect  of  the  wound,  the  rectus  can  be  divided  to  the  needed  extent  to  secure 
it,  after  ligature  of  the  epigastric  vessels.  There  is  much  to  be  said  in  favor 
of  this  incision  when  the  diseased  processes  are  located  low  in  the  iliac  fossa 
and  invade  the  pelvic  cavity. 

Fowler  exposes  the  aponeurosis  of  the  external  oblique  by  reflecting  a 
triangular-shaped  flap  of  integument  and  fascia,  the  upper  border  extending 
transversely  between  the  anterior  superior  spinous  process  and  the  rectus 
abdominis  muscle,  and  the  inner  from  the  termination  of  the  former  down- 
ward, parallel  with  the  edge  of  the  rectus,  two  and  a  half  inches  or  more, 
as  circumstances  require.  Then  expose  the  external  oblique  still  more  by 
counter  traction  made  from  the  middle  of  the  upper  border  and  at  the  lower 
angle ;  divide  the  external  oblique  structure  downward  and  forward  about 
three  or  more  inches  to  the  border  of  the  rectus  sheath ;  make  counter  trac- 
tion at  right  angles  with  the  preceding,  thus  exposing  a  greater  area  of  the 
wound ;  make  a  vertical  incision  into  the  outer  limit  of  the  sheath  of  the 
rectus,  two  or  three  inches  in  length ;  retract  the  rectus  muscle  and  the  epi- 
gastric vessels  well  toward  the  median  line ;  retract  the  outer  border  of  the 
divided  aponeurosis  in  the  opposite  direction,  thus  exposing  the  internal 
oblique ;  divide  transversely  the  internal  oblique  and  transversalis  muscles 
in  the  course  of  their  fibers,  extending,  if  need  be,  the  incision  into  the  pos- 
terior wall  of  the  sheath  of  the  rectus;  draw  asunder  the  borders  of  this 
incision ;  divide  the  fascia  and  peritonaeum  on  the  finger  from  within  out- 
ward ;  expose  and  remove  the  appendix  in  the  manner  fitting  the  case ; 
replace  and  unite  the  deep  parts  in  position  with  continuous  catgut  sutures. 

The  Eemarlcs. — The  incised  edge  of  the  sheath  of  the  rectus  should  be 
carefully  closed  along  with  the  aponeurosis  of  the  external  oblique.  Xo  part 
of  the  rectus  muscle  should  be  included  in  the  sutures.  Fowler  regards  this 
method  as  especially  applicable  to  cases  with  limited  impaction.  Fowler 
claims  for  this  method  the  following  : 

1.  "  Ready  access  is  gained  to  the  ileo-ca?cal  region,  and   ample  room 


726  OPERATIVE   SURGERY. 

secured  for  all  necessary  manipulation  in  the  class  of  cases  for  which  it  is 
designed. 

2.  "  Weakening  of  the  abdominal  wall  and  the  liability  to  surgical  hernia 
are  reduced  to  a  minimum  by  (a)  incising  the  important  musculo-aponeurotic 
structures  in  such  a  manner  as  to  secure  immediate,  firm,  and  permanent 
union  ;  and  (b)  avoiding  injury  to  the  vascular  and  nerve  supply  of  the  parts 
involved  in  the  incisions." 

The  General  Comments. — Xo  one  method  of  operative  procedure  is  equally 
applicable  to  all  cases.  Therefore,  a  careful  consideration  of  the  history  and 
the  local  manifestations  of  each  case  should  direct  the  placing  of  the  primary 
incision,  and  thereafter  it  should  be  modified  to  meet  the  demands  of  present 
and  final  security  of  the  patient.  Obese  patients,  and  those  affected  with  dis- 
ease or  subjected  to  unsanitary  surroundings,  should  be  approached  surgically 
with  caution  when  feasible,  as  these  agencies  often  exercise  a  potent  influ- 
ence opposed  to  a  favorable  outcome.  After  exposure  of  the  parietal  peri- 
tonaeum through  the  incision,  limited  or  extended  palpation,  secured  by 
separation  of  the  peritonaeum  from  the  fascia  at  the  sides  of  the  wound,  can 
be  practiced  to  determine  the  characteristics  of  the  growth.  If  the  stump  of 
the  appendix  be  rigid,  it  is  not  advisable  to  make  forcible  attempts  at  in- 
vagination, since  they  will  likely  fail  entirely  or  lead  to  deception  by  their 
incompleteness.  Disappearance  of  the  appendix  by  maceration  in  the  fluids 
of  the  disease  is  more  perplexing  than  strange,  since  it  may  lead  to  useless 
and  unwise  search  for  the  diseased  organ.  Inasmuch  as  wide  and  firm 
packing  of  the  wound  provokes  delayed  and  defective  repair,  impedes  drain- 
age, and  favors  the  formation  of  constricting  bands,  the  gauze  dressing  should 
be  placed  in  the  wound  in  an  orderly  manner  and  in  small  amount,  so  as 
to  encourage  drainage  and  limit  as  much  as  possible  the  production  of  new 
tissue.  Counter  openings  for  the  purpose  of  the  introduction  of  drainage 
agents  can  be  wisely  employed,  when,  for  any  reason,  inadequate  drainage 
can  not  be  secured  through  the  primary  incision.  Extended  involvement  of 
the  peritoneal  cavity  and  its  contents  suggests  the  necessity  of  establishing 
counter  drainage.  The  administration  of  constipating  agents,  and  those 
calculated  to  disguise  important  manifestations  of  disease,  especially  opium 
and  its  derivatives,  should  be  avoided  when  justifiable.  Saline  cathartics  are 
advised  to  secure  early  action  of  the  bowels  and  to  obviate  constipation.  The 
introduction  into  the  small  intestine,  through  an  incision  or  by  means  of  a 
syringe,  of  a  solution  of  magnesium  sulphate,  as  advised  by  McCosh,  is  com- 
mendable, especially  in  septic  cases.     Avoid  eventration,  if  possible. 

The  Precautions. — It  happens  sometimes  that  the  origin  of  the  appendix 
is  not  associated  with  the  termination  of  the  fibrous  bands  of  the  ca?cum, 
a  fact  that  should  be  recognized,  otherwise  unfortunate  conclusions  might 
follow  the  absence  of  the  usual  relation  of  these  parts.  The  rolling  outward 
or  inward  of  the  cfecum  by  the  contraction  of  old  adhesions  often  presents 
to  the  judgment  of  the  operator  annoying  anatomical  problems.  The  liga- 
turing of  the  appendix  outside  the  seat  of  the  obstruction  of  the  lumen  may 
afford  no  relief,  and  even  provoke  thereafter  a  renewal  of  the  attack  by  the 
establishment  of  an  unventilated  nmcous  chamber  at  the  distal  end  of  the 


()1m:i;.\'I'i<»n's  ox  visckija  con'mictki)  wimmi   I'Kurrox.KUM.    727 

stuni]).  Tliu  tisciTtuinint'iit  of  the  pcrmc'iit)ility  of  tlio  stuiiij)  by  the  intro- 
duction tliroiitrh  it  into  tlic  Civcum  of  u  ])robc',  and  the  strctcliinir  of  it  with 
forcei)S  l)efoi'c  liiial  liiiatiire,  are  each  often  of  signal  importance  in  the  tech- 
nique preventive  of  recurrence.  The  burial  in  the  wall  of  tiu^  cecum  of  an 
impermeable  or  diseased  stumi)  of  the  appeiulix  should  Ijc  avoided  for  appar- 
ent reasons.  In  raising  the  appendix  into  the  wound  for  removal,  a  small 
diseased  portion  of  it  may  be  torn  away  and  remain  attached  by  adhesions  to 
a  somewiiat  distant,  i)art.  The  retained  fragment  nuiy  not  only  become  the 
source  of  renewed  morbid  action,  but  the  ruptured  appendix  may  incite  in- 
flammation by  infection  of  the  serous  surfaces  along  the  line  of  its  with- 
drawal. A  careful  examination  should  therefore  be  made,  to  determine  the 
integrity  of  the  appendix  before  the  final  technique  is  completed  ;  and,  too, 
caution  should  be  exercised  in  exposing  and  raising  it  upward  for  removal, 
to  avoid  uiiprepared-for  rupture  and  infection.  Chromicized  catgut  can  be 
employed  to  tie  the  stump  in  all  instances;  silk  can  be  used  in  all  except 
the  infected  cases.  The  sheath  of  the  rectus  abdominis  should  not  be 
incised  when  it  is  practicable  to  avoid  it,  for  this  act  may  interfere  with 
satisfactory  union  and  repair,  and  affords  opportunity  for  infiltration  of 
unwholesome  fluids  along  the  sheath  and  muscular  fibers;  and,  too,  the 
branches  of  the  dee.])  epigastric  artery  would  be  exposed  thereby  to  untimely 
injury.  If  the  intestine  be  adherent  to  the  abdominal  wall  at  the  seat  of  the 
abdominal  incision,  great  prudence  must  be  exercised  to  avoid  a  precipitate 
or  deliberate  involvement  of  the  lumen  of  the  gut  with  the  knife.  The 
pinching  up  of  the  peritom^um  with  the  thumb  and  finger,  as  in  hernial 
protrusions,  to  determine  the  presence  of  adhesions,  can  be  practiced  here 
with  excellent  result.  The  trunks  of  the  nerves  supplying  the  abdominal 
muscles  should  be  carefully  preserved  from  injury,  since  their  division  will 
cause  paralysis  and  weakening  of  the  part  of  the  abdominal  wall  to  which 
they  are  distributed.  The  placing  of  a  drainage  tube  in  contact  with  a  de- 
nuded spot  of  the  intestinal  wall  is  liable  to  provoke  sloughing  at  that  point 
and  cause  ftecal  fistula.  The  possibility  of  the  presence  of  constriction  of 
the  bowel  at  the  time  of  or  soon  after  operation,  by  old  or  recent  adhesions, 
should  not  be  disregarded,  since  the  symptoms  of  this  condition  may  be 
confounded  with  those  of  the  primary  trouble.  All  bleeding  points  should 
be  carefully  caught  and  tied.  The  writer  recalls  two  instances  of  secondary 
hemorrhages  following  operation  for  extensive  acute  appendicitis,  one  very 
annoying,  but  finally  controlled  ;  the  other  unexpected  and  fatal  because  of 
infection  of  an  extensive  subperitoneal  extravasation  of  blood. 

The  After-treatment. — After  the  operation  the  patient  is  wiped  dry,  the 
dressings  are  applied  and  confined  in  place  with  a  broad  binder  so  fastened 
below  as  to  prevent  slipping  up  and  exposing  the  wound.  The  patient  is 
then  placed  in  a  warm  bed,  provided  with  bottles  of  hot  water  if  needed, 
and  kept  quiet.  Rarely,  indeed,  is  nourishment  given  during  the  first  twelve 
hours,  nor  soon  after  this  if  gastric  irritation  be  noted.  In  such  cases  hot 
water  in  small  amounts  may  be  sipped  to  quench  thirst.  Pain,  intestinal 
distention,  vomiting,  retention  of  urine,  etc.,  are  treated  as  they  arise,  avoid- 
ing, when  possible,  the  use  of  opium  and  its  derivatives.     The  pulse,  tem- 


Y28  OPERATIVE  SURGERY. 

2)er;itiire,  and  respiration  sliould  be  taken  before  the  operation  and  at  regular 
intervals  thereafter,  so  long  as  the  patient  remains  in  bed.  Peptonized 
milk,  koumiss,  milk  and  Vichy,  and  the  like,  are  suitable  foods  at  the  begin- 
ning; later  more  substantial  articles  can  be  given.  In  simple  cases  the 
wound  is  redressed  in  four  or  five  days,  stitches  are  removed,  fresh  dressing 
is  applied,  and  the  patient  kept  quiet  in  bed  for  ten  or  twelve  days  longer, 
when  he  is  permitted  to  rise.  If  drainage  has  been  employed  it  should  be 
removed  as  soon  as  it  has  served  its  purpose.  Textile  fabric,  especially  iodo- 
form gauze,  when  applied  for  reparative  needs,  should,  after  thorough  satu- 
ration, be  removed  by  twisting  on  the  second  or  third  day.  Gentle  irrigation 
or,  better  still,  careful  wiping  of  the  cavity  is  practiced  in  the  instances  of  the 
use  of  drainage  for  the  elimination  of  inflammatory  products  and  of  their 
objectionable  substances.  In  su2)purating  cases  the  jiatieut  should  remain 
in  bed  for  two  or  three  weeks,  or  until  substantial  healing  has  taken  place. 
The  wearing  of  an  abdominal  support  for  some  time  thereafter,  especially  by 
those  exposed  to  the  influences  of  muscular  effort,  is  a  wise  provision.  It 
sometimes  happens  that  the  occurrence  of  symptoms  indicative  of  intestinal 
obstruction,  or  of  extending  peritonitis,  or  localized  suppuration,  require  that 
the  wound  be  reopened,  and  perhaps  that  additional  incisions  be  made,  to 
aff"oi'd  the  necessary  relief. 

Intestinal  Perforation  in  Typhoid  Fever. — In  1884  Leyden  first  proposed 
operative  measures  for  the  relief  of  this  heretofore  almost  always  fatal  com- 
plication. Since  that  time  150  cases  of  operation  for  its  relief  have  been 
rejiorted  (Keen).  The  great  majority  of  the  perforations  occur  from  the 
second  to  the  sixth  week  inclusive,  the  third  (24.8  per  cent)  and  the  fourth 
(21.7  per  cent)  being  the  most  prolific  in  this  respect  (Fitz). 

The  ileum  is  the  seat  of  perforation  in  81.4  per  cent,  the  large  intestine 
in  12.9  per  cent,  and  the  vermiform  appendix  in  3  per  cent  of  the  cases 
(Fitz).  The  jejunum  and  Meckel's  diverticulum  are  perforated  in  rare 
instances.  The  transverse  colon  suffers  least,  and  the  descending  and  sig- 
moid flexure  the  most  frequently  of  the  subdivisions  of  the  large  intestine 
(Hawkins). 

Usually  but  a  single  perforation  is  present,  but  sometimes  several  are 
found,  and,  besides,  points  of  extreme  thinness  denoting  imminent  perfo- 
ration are  often  discovered.  The  perforations  vary  in  size,  being  in  one 
instance  so  small  as  to  often  baffle  detection,  in  another  quite  readily  dis- 
coverable or  even  distinctly  gaping. 

The  Oper'atmi. — The  operation  should  be  performed  after  subsidence  of 
shock  and  as  j^romptly  as  is  consistent  with  the  welfare  of  the  patient.  If 
the  infection  be  general,  as  is  usually  the  case,  make  the  primary  incision  in 
the  median  line ;  if  circumscribed,  make  it  over  the  circumscribed  area, 
therefore,  laterally ;  but  in  either  instance  of  sufficient  size  to  permit  of 
prompt  and  free  manipulations.  When  apparent,  extravasated  contents  of 
the  intestine  should  be  removed  by  careful  wiping,  aided  by  a  gentle  stream 
of  hot  saline  solution,  to  avoid  a  needless  spread  of  infection  from  liandling 
of  the  intestines. 

In  the  search  for  the  perforation,  one  is  guided  by  the  knowledge  of  the 


orKRATlUNS   UN    VLSCKKA   CUNNELTED    WITH    I'KKl'ruNJaM.     Jsjy 

relative  froquoncy  of  the  seat  of  the  occurrence,  and  In'  tho  local  evidences 
of  the  inllainiiiation,  extravasation,  etc.  As  soon  as  found,  the  boi'ders  of 
the  opening  and  the  continuous  thinned  surface  are  turned  in  without 
trimming,  and  united  by  the  mattress  suture.  If  the  amount  of  the  inturn- 
ing  be  such  as  to  cause  too  great  closure  of  the  bowel,  then  either  enterec- 
torny  or  enterostomy  should  be  practiced  according  to  the  condition  of  the 
])atient;  usually  the  latter  is  preferable.  Search  for  a  second  perforation 
and  for  weakened  spots  in  the  intestine  is  required  when  warranted  by  the 
condition  of  the  patient;  but,  inasmuch  as  most  of  the  perforations  occur 
witliin  three  feet  of  the  ileocivcal  valve,  there  is  but  little  that  can  be  gained 
for  the  much  that  may  be  sacrificed  by  a  larger  and  more  extended  exami- 
nation. 

As  thorough  cleansing  as  practical^le  of  the  peritoneal  cavity  and  of  the 
contents  should  be  employed,  either  by  a  systematic  wiping  with  sponges 
wrung  out  of  a  hot  saline  solution  (Finney)  or  by  a  careful  flushing  with 
this  fluid.  While  in  some  instances  it  may  be  permissible  to  close  the 
abdomen  without  drainage,  in  the  majority  of  cases  drainage  should  be 
employed. 

The  ability  to  determine  the  presence  or  absence  in  the  abdominal  cavity 
of  infective  agents  in  advance  of  operation  with  the  view  of  earlier  action, 
and  deciding  the  question  of  the  employment  of  drainage,  is  very  important, 
but  will  remain  for  a  long  time  in  general  practical  abeyance  in  other  than 
hospital  practice,  because  of  the  want  of  opportunity  and  the  disinclination 
to  carry  it  into  effect  in  the  more  common  paths  of  action. 

The  Precautions. — Careful  scrutiny,  aided  by  a  suitable  light,  is  requisite 
to  the  detection  of  minnte  or  widely  separated  perforations,  and  even  then, 
prolonged  or  vigorous  efforts  may  neutralize  the  advantages  arising  from  a 
more  discreet  course.  The  mattress  suture  of  Halsted  (page  G2'^)  is  the  best 
that  can  be  employed  because  of  the  securer  grasp  on  the  softened  structures, 
and  of  the  greater  rapidity  of  its  application,  especially  as  relates  to  tying, 
since  in  this  variety  one  knot  meets  the  purposes  of  two  by  the  interrupted 
method.  It  is  wise  in  all  cases  to  examine  the  appendix,  not  only  because  of 
its  occasional  involvement  in  typhoid  fever,  but  also  because  it  alone  may  be 
at  fault.  The  employment  of  local  cocain  anaesthesia,  instead  of  general 
anesthesia,  affords  the  patient  the  better  chance  for  recovery. 

The  Results. — The  death  rate  without  operation  is  fully  95  per  cent.  In 
116  cases  operated  on,  22.7  per  cent  recovered.  In  operation  from  eighteen 
to  twenty-five  hours  after  the  attack  31.4  per  cent  recovered  ;  twelve  to 
eighteen  hours  after,  29.1  per  cent ;  eight  to  twelve  hours  after,  26. G  per 
cent;  and  during  the  first  eight  hours,  10.5  per  cent  recovered  (Keen). 

Rapidity  of  action  in  this  operation  influences  largely  the  results.  In  but 
one  ra>:e  in  wliich  an  lionr  or  lonirer  was  taken  did  recovery  occur. 

Peritonitis  dependent  on  perforation  from  other  than  typhoid  ulceration 
is  not  unusual,  and  often  is  entirely  unanticipated.  Perforation  of  the  intes- 
tine, dependent  on  various  morbid  processes  and  on  the  rupture  of  the  limit- 
ing walls  of  infective  accumulations,  is  often  foreshadowed  by  symptoms 
peculiar  to  the  miture  and  location  of  the  causative  factors.     In  such  cases 


730  OPERATIVE   SURGERY. 

the  diagnosis  of  rupture  is  aided  by  a  knowledge  or  suspicion  of  the  existence 
of  the  contributing  cause. 

Generally  fatal  septic  peritonitis  is  more  often  the  result  of  such  ha])pen- 
ings  than  is  the  less  harmful  adhesive  variety.  The  shock  attendant  on  this 
class  of  cases  differs  in  no  practical  regard  from  that  following  typhoid  per- 
forations. However,  the  degree  of  pain  and  the  site  of  the  primary  mani- 
festations are  modified  chiefly  by  the  seat  of  the  infection  and  the  nature 
and  the  amount  of  the  infecting  agents. 

Tlie  opei'ative  technique  differs  in  no  important  concern  in  these  cases 
from  that  of  the  typhoid  until  after  the  peritoni^um  is  divided.  The  exami- 
nation is  then  directed  to  that  portion  of  the  abdominal  cavity  toward 
which  the  characteristics  of  the  extravasated  fluid,  the  inflammatory  phe- 
nomena, and  the  previous  history  of  the  case  point.  The  removal  of  the 
infecting  agents  (page  612),  the  search  for  the  perforation,  the  treatment  of 
the  distended  intestines  (pages  6GG  and  690),  the  cleansing  and  drainage  of 
the  peritona3um  (page  613),  are  conducted  as  promptly  and  efficiently  as  cir- 
cumstances will  permit,  always  remembering  that  judicious  haste  is  a  great 
desideratum  in  the  securing  of  final  recovery. 

The  Ee)narks. — The  escape  of  odorless  gas  and  the  presence  of  acid  fluid 
along  with  gastric  contents  denote  stomach  involvement.  If  the  gas  be 
offensive,  or  the  fluids  of  a  purulent  or  fiscal  character,  the  portion  of  the 
intestine  to  which  they  normally  belong  is  likely  to  be  the  seat  of  the  open- 
ing. The  presence  of  pus,  bile,  urine,  etc.,  indicate  not  only  the  probable 
cause  of  this  trouble,  but  also  the  source  of  the  fluid. 

The  elimination  from  the  distended  intestines  of  their  objectionable  con- 
tents by  punctures  or  incisions  of  the  gut  is  often  difficult  and  perhaps  im- 
possible, because  of  intestinal  paralysis  and  the  hindrance  arising  from  the 
acute  flexions  of  the  intestine  dependent  on  a  tense  mesentery. 

The  combating  of  shock  by  local  warmth,  hot  saline  injections,  and  me- 
dicinal stimulation  is  especially  indicated  in  these  cases.  The  elimination 
of  the  infecting  agents  that  may  remain  behind  in  the  abdominal  cavity  is 
facilitated  by  the  use  of  saline  cathartics  and  the  leaving  within  the  cavity 
of  a  portion  of  the  saline  fluid  (see  page  613). 

The  Results. — The  results  of  operation  for  perforations  dependent  on 
appendicitis,  wounds,  etc.,  are  already  treated  under  their  proper  headings. 
When  arising  primarily  from  unrecognized  causes,  the  death  rate  varies 
from  15  to  30  per  cent. 

Peritonitis  due  to  tuberculosis  can  be  wisely  treated  in  proper  cases  by 
abdominal  section.  An  incision  is  made  usually  in  the  median  line,  and  of 
sufficient  length  to  permit  of  easy  removal  of  the  fluid  by  sponging  or  si- 
phonage,  the  drying  of  the  peritoneal  surfaces  by  carefully  applied  sponge 
or  gauze  pressure,  and  coincident  examination  of  the  exposed  abdominal 
contents.  The  flushing  of  the  cavity  after  evacuation  of  the  fluid  by  means 
of  the  saline  or  boric-acid  solution  is  favorably  regarded  in  the  absence  of 
infective  agents.  In  simple  cases  the  abdominal  wound  is  closed  promptly, 
and  the  patient  kept  quiet  in  bed.  In  those  cases  characterized  by  the  pres- 
ence of  pus  in  the  abdomen,  or  other  infective  influences,  drainage  should 


(H'KI{A'ri(>NS   ON    VISCKKA    ('( »NN  K(  "l"KI)    WI'I'II    I'KKI'I'oN.l'.l'.M.     731^ 


be  practiced  from  tin-  hoginniiifif,  while  in  simpler  cases  it  need  not  be  em- 
ployed unless  railiire  oi"  cure  follows  the  siit'er  [)liin — the  imnicdiate  closure 
of  the  wouiul. 

The  Jivnutrlis. —  Abdomiiuil  section  in  the  suppurative  varieties,  espe- 
cially if  general  or  in  the  form  of  multiple  cysts,  is  very  unsatisfactory. 
The  dry  aiul  ulcerating  forms  of  the  disease  olfer  indifferent  prospects  of 
success.  If  permanent  drainage  be  established,  continuous  care  must  l)e 
exercised  to  prevent  the  subse(juent  occurrence  of  infection  of  the  abdomi- 
nal cavity. 

The  Nesitl/s. — In  children,  in  favorable  cases,  60  per  cent  of  cures  are 
reported,  with  but  a  trivial  mortality  from  tlie  operation  alone.  In  adults 
of  the  same  class  of  cases,  about  38  per  cent  were  cured. 

Operation  in  the  dry  and  ulcerated  forms  of  the  disease  is  followed  by  a 
death  rate  of  about  75  per  cent;  in  the  suppurative  multilocular  cystic  kind 
but  few  recover;  in  the  inflammatory  localized  suppurative  form  the  opera- 
tive outcome  is  quite  favorable. 

Faecal  Fistula  and  Artificial  Anus. — The  operative  cure  of  a  fwcal  fistula 
or  of  an  artificial  anus  is  frequently  difficult  and  may  be  impossible.  The 
important  factors  of  success  in 
these  cases  are  a  sterile  wound 
and  proper  union  of  the  serous 
surfaces.  The  vigorous  assaults 
on  these  desiderata  of  intestinal 
infection  and  the  effects  of  pre- 
vious inflammatory  action  often 
so  handicap  well-directed  surgical 
efforts  as  to  render  the  outcome 
quite  problematical  even  in  ap- 
parently simple  cases.  A  long  or 
devious  sinus  intimately  connect- 
ed with  adjacent  intestine  de- 
mands the  exercise  of  the  most 
scrupulous  care  in  its  removal  to 
prevent  immediate  or  remote  in- 
volvement of  additional  intestine 
dependent  on  direct  incision,  or 
the  sloughing  incident  to  im- 
paired nutrition  due  to  the  in- 
jury inflicted  on  the  intestinal 
coats.  The  removal  of  the  com- 
munication with  tlie  bowel  is  a 
common  step  in  the  treatment 
of  these  conditions,  and  is  sup- 
plemented by  either  of  the  fol- 
lowing methods  of  intestinal  repair  best  suited  for  the  case :  1,  Simple  inci- 
sion and  closure  of  the  opening  by  sewing ;  2,  elbowing ;  3,  enterectomy 
and  direct  union  by  (a)  end-to-end  sewing  ;  (b)  Maunsell's  method ;  (c)  Mur- 


'iG.  9o0. — Diagrammatic  illustration  of  fa>cal 
fistula  and  artificial  anus.  u.  Upper  bowel. 
/.  Lower  bowel.  1.  Fistula  without  a  spur. 
2.  Fistula  with  an  incomplete  spur.  3. 
False  anus  with  complete  spur.  4.  Double 
faecal  fistula. 


732 


OPERATIVE   SURGERY. 


phy's  button;  or  indirect  union  by  lateral  anastomosis  in  the  manner  already 
indicated. 

The  preparatory  treatment  of  the  patient  for  operation  contributes  very 
much  indeed  to  a  successful  outcome.  The  intestinal  canal  should  be  evacu- 
ated thoroughly  by  saline  cathartics,  supple- 
mented by  copious  rectal  injections  of  ster- 
ilized water  if  the  colon  be  the  part  in- 
volved, long  enough  before  the  operation  to 
permit  of  the  escape  of  the  fluids  from  the 
bowels.  The  tissues  around  the  opening 
should  be  made  healthy  and  the  borders  be 
thoroughly  cleansed  by  washing  and  scrub- 
bing, and  softened,  too,  by  emollient  appli- 
cations if  unusually  hard  and  rigid.  Fluid 
food  alone  should  be  given  the  patient. 
Tlie  first  step  in  the  operation  relates  to 
the  isolation  of  the  sinus  leading  to  the 
opening  in  the  gut.  This  step  must  be  care- 
fully practiced  to  jDrevent  infection  of  the 
wound  by  the  agency  of  the  lining  mem- 
brane of  the  sinus,  and  also  to  avoid  injury 
of  intestinal  folds  lying  contiguous  to  and 
perhaps  intimately  connected  with  it.  The 
removal  of  the  sinus  is  immediately  pre- 
ceded by  scraping  and  scrubbing  of  its 
walls  with  antiseptic  fluid,  followed  by  the 
passage  through  it  into  the  intestine  of  a 
small  sponge  retained  in  place  by  means  of  a  string  attachment,  the  free 
end  of  which  remains  without.     The  external  opening  of  the  sinus  is  then 

closed  tightly  by  silk  sutures  passed  somewhat 
deeply  through  the  borders  and  tied,  the  ends 
remaining  uncut.  After  thorough  cleansing  of 
the  part  the  sutures  are  grasped  collectively 
by  means  of  forcipressure  and  drawn  upward 
by  the  surgeon  or  an  assistant  so  as  to  ele- 
vate the  included  tissue  (Fig.  931),  and  an  in- 
cision an  inch  or  so  in  length,  according  to 
requirements,  is  made  with  a  sharp  scalpel  at 
,    ^  •  ^  either   side   of  the   elevated    end  (i,  d)  in  the 

S  ~  tr  :,i;„^yiii!i^    direction  of  the  long  axis  of  the  intestine,  if 

the  colon,  or  vertically  if  the  small  intestine  be 
the  one  involved.     The  corresponding  extremi- 
ties of  these  incisions  are  then  connected  with 
FiG.932.-Thetreatme';rtof fecal    ^ach  other  by  two  curved  ones  {a,  a')  carried 
fistula    and    artificial    amis,    one  at  either  side  of  the  opening  about  half  an 
a.  Sutures,     b.  Portion   re-    j^^^j^  fj.^j-,-,  ^j^^  border.     The  dissection  is  con- 
moveu.      c.    u  all   of    sinus. 
d.  Lumen  of  sinus.  tinned  carefully  either  along  the  outer  («,  a  )  of 


Fk;.  931.— The  treatment  of  fa'cal 
fistula  and  artificial  anus,  o,  a. 
Curved  incisions,  h,  d.  Vertical 
incisions,  c.  Border  of  outer 
wall  of  fistula. 


OPKRATIoNS   ON    VISCKIIA    ( 'oNN  KCrKD    WITH    I'KUri'OX.Kr.M.     733 

these  incisions  only,  or  conibiiiedly  with  one  (0)  or  botii  (/>,  d)  of  the  straight 
incisions  outside  of  the  sinus  down  to  the  gut,  which  is  then  raised  up  well 
into  the  wound.  The  peritoneal  cavity  may  or  may  not  be  involved  by  the 
dissection,  depending  on  the  extent  of  the  adhesions,  the  desire  to  coapt  the 
serous  surfaces  of  the  bowel  in  the  re])air,  or  the  ignoring  entirely  of  these 


y/^ 


Fig.  033 


Fig.  934. 


Fig.  933. — Diagrammatic  illustration  of  closure  of  fistula,  the  dissection  not  involving 
the  peritoneal  cavity,  ft.  Fistula,  g.  Granulation  lining,  s.  Integument  and  sub- 
cutaneous tissue,  in.  Muscular  tissue.  /.  Peritoneal  fascia  and  periton;eum.  ad. 
Adhesion  between  bowel  and  parietal  peritonaeum,  b.  Bowel.  Dotted  line  indicates 
course  of  incision  for  removal  of  sinus.     Wound  closed  with  sutures. 

Fig.  934. — Diagrammatic  illustration  of  closure  of  artificial  anus.  ad.  ad.  Adhesions 
between  serous  surfaces  of  spur,  and  between  bowel  and  jieritonaHim.  b.  Bowel. 
/.  Peritonanim  and  subperitoneal  fascia,  m.  Muscular  tissue,  s.  Integument  and 
subcutaneous  tissue,  sp.  The  spur.  Dotted  line  indicates  course  of  incision  for 
removal  of  fistula.     Wound  closed  with  sutures. 


surfaces  followed  by  the  apposition  of  non-serous  structures  only  in  the 
closure  of  the  opening.  The  sinus  is  then  removed  (Fig.  932),  and  if  the 
opening  be  small  the  borders  are  inverted  and  closed  by  sewing  in  the  man- 
ner already  expressed  (Figs.  792  and  862,  d).  If  the  peritoneal  cavity  be  not 
involved,  serous  tissues  are  not  utilized,  and  the  method  of  union  is  indi- 
cated in  the  foregoing  illustration  (Fig.  934).  If  the  area  of  adhesion  be 
unusually  limited  in  extent  in  this  instance,  the  peritoneal  cavity  may  be 
involved  and  serous  surfaces  are  then  approximated  in  the  repair.  If  serous 
surfaces  be  desired  for  repair,  the  dissection  must  be  extended  beyond  the 
limits  of  the  area  of  adhesion,  thus  freely  opening  the  peritoneal  cavity  and 
calling  for  a  corresponding  increase  in  vigilance.     If  the  intestinal  opening 


i34 


OPERATIVE   SURGERY. 


be  so  extensive  as  to  forbid  simple  closure,  "  elbowing  "  (Figs.  8G5  and  866,  d) 
may  be  practiced,  which  calls  for  peritoneal-cavity  involvement  and  serous- 
surface  coaptation.  If  neither  of  the  preceding  plans  be  prudent,  removal 
of  the  segment  of  gut  involved  in  the  fiistula  and  the  adjacent  adhesions 
should  be  practiced  (enterectomy),  and  the  repair  completed  by  end-to-end 
union  (page  058  et  seq.)  by  the  method  best  intended  to  meet  the  demands 
of  the  case.  Lateral  anasfoinosis  (page  G-ii  et  seq.)  may  be  practiced  after 
enterectomy,  if  necessary,  and  even  without  it  in  the  small  intestine  by 
the  Murphy  button,  by  sewing,  by  plates,  bone  and  potato  bobbins,  etc., 
thus  establishing  a  short  circuit  (Fig.  829)  and  thereby  eliminating  the  loop 
of  intestine  involved  in  the  sinus  from  the  line  of  faecal  flow,  which  some- 
times results  in  spontaneous  cure. 

Greig  Smith's  Method  of  Treatment. —  Greig  Smith  aimed  to  cure  the 
fistula  without  peritoneal-cavity  involvement.  After  proper  cleansing  of 
the  opening  and  plugging  to  prevent  infection,  an  incision  is  made  in  the 
direction  of    the  underlying  muscular  fibers,  outward  for  an  inch  or  two 

from  near  the  margin  of,  but 


not  involving,  the  fistula  (Fig. 
931,  I),  d).  The  inner  end  of 
the  incision  is  carried  around 
the  fistula  outside  the  cica- 
tricial border  (c),  and  the  dis- 
section is  continued  carefully 
downward  to  the  subserous 
tissue  along  the  entire  line  of 
the  primary  incision  (Fig.  933). 
The  subserous  and  peritoneal 
tissues  are  separated  from  the 
superimposed  structures  care- 
fully with  the  finger  for  two  or 
three  inches  around  the  sinus, 
sufficiently  at  least  to  permit 
the  sinus  opening,  the  contigu- 
ous intestine,  and  the  parietal 
peritonaeum  to  be  raised  well  up  into  the  wound.  The  fistulous  tract  is 
removed  and  the  opening  closed  by  the  infolding  of  the  freshened  surfaces 
and  their  union  with  each  other  by  a  primary  row  of  interrupted,  and  a 
secondary  row  of  continuous  sutures,  as  in  other  instances  of  intestinal 
sewing.  The  abdominal  wound  is  then  closed  in  the  usual  manner.  By 
this  method  the  peritoneal  cavity  is  not  involved,  the  minimum  of  danger 
is  incurred,  and  entire  dependence  is  placed  on  the  union  of  non-serous 
surfaces.  Smith  gives  notable  instances  of  complete  success  by  this  plan, 
and  regards  the  apposition  of  serous  surfaces  as  not  essential  to  cure.  It 
is  apparent  at  once  that  the  incision  can  be  extended  through  the  peri- 
toneum, so  as  to  utilize  the  serous  surfaces  for  repair  when  desired.  Senn 
advises  that  the  fistulous  opening  be  closed  tightly  by  closely  applied  sutures, 
instead  of  by  plugging  it  with  cotton  or  gauze,  not  only  because  the  former 


A 
Fig.  985. — Overcoming  spur  by  rubber  tube, 
held  in  place  by  string  or  by  wire. 


Tube 


OPKUATIONS   ON    VISCKIJA    CONN'KCTP:i)    WITH    IMllMToN vKlM.     735 


is  the  more  secure,  but  tliereafter  tlie  united   bordeis  ciiu  he  turned  in  and 
buried  by  Lembert  sutures. 

Xot  infrequently  a  projection  or  spur  of  the  wall  of  the  intestine  reaches 
upward,  so  as  to  direct  the  fiecal  How  through  the  opening  (Figs.  930  and 
938).  Sometimes  prolapsed  mucous  membrane  of  continuous  or  peduncu- 
lated arrangement  olTers  an  obstacle  to  the  fjccal  ilow  along  the  intestine. 
The  ill  elTccts  of  the  spur  and  the  other  obstacles  should  be  remedied  before 
the  attemi)t  of  final  closure  is  made.  The  spur  can  be  overcome  wholly  or 
in  part  by  the  introduction  into  the  intestine  of  a  large  sized  piece  of  rubber 
tubing  so  placed  as  to  depress  the  spur.  The  tubing  is  held  in  position  by 
fine  silver  wire,  or  by  a  string  passed  through  the  wall  but  not  into  the  lumen 
of  the  tube,  and  fastened  securely  on  the  outer  surface  of  the  abdomen  (Fig. 
935).  Inasmuch  as  Senn  regards  flexion  of  the  bowel  as  the  prime  cause  of 
the  spur,  he  advises  that  the  opening  be  closed  by  sewing  transversely  instead 
of  longitudinally  as  is  the  common  practice.  The  pedunculated  mucous 
structures  can  be  drawn  up  and  tied  off  with  fine  silk  if  their  attachments 
be  small.  The  author  in  one  instance  removed  a  spur  in  ten  days  with- 
out trouble  by  the  application  to  it  through  the  opening  in  the  bowel  of  a 
small-sized  Murphy  button.  Robson  cured  a  facal  fistula  complicated  with 
stricture  of  the  intestine  by  exposing  and  dividing  the  stricture  in  the  long 
axis  of  the  intestine,  followed  by  the  introduction  of  a  decalcified  bone 
bobbin  into  the  lumen  and  its  confinement  in  place  by  closure  over  it  of 
the  denuded  tissue  by  transverse  suturing.  The  mucous  margins  were 
united  by  a  continuous  catgut,  and  the  serous  by  a  silk,  suture.  The 
patient  made  a  prompt  and  uneventful  recovery,  and  has  remained  well 
since  that  time. 

Instrumental  methods  of  removal  of  the  spur,  with  a  view  of 
fistulous  opening,  are  among  the  old- 
est of  practice.  At  the  present  time 
much  less  notice  is  given  them  than 
formerly.  The  enterotomes  of  Du- 
puytren,  Collin,  etc.  (Fig.  936),  are 
well-known  instruments.  The  entero- 
tome  devised  by  Gross  is  better  than 
either  of  the  preceding,  because  it  not 
only  divides  but  removes  the  spur  (Fig. 
939).  The  method  of  Bodine  (page 
679),  directed  both  to  the  formation 
and  removal  of  the  spur,  is  the  latest 
and  best  of  the  series. 

The  Remarks.  —  The  enterotome 
should  be  so  applied  as  not  to  open 
into  the  peritoneal  cavity,  and  should 
remain  from  one  to  two  weeks,  or  un- 
til liberated  by  necrosis  of  the  included 
tissues.  Only  sufficient  of  the  spur  should  be  grasped  to  effect  the  removal 
of  the  requisite  amount,  thereby  limiting  the  danger  of  perforation   and 


Fig.  9:?6.— The  enterotomes 


tren  s  enterotome. 
tome. 


Diipuy- 


b.  Collin's  entero- 


736 


OPERATIVE  SURGERY. 


the  possibility  of  including  in  the  grasp  of  the  instrument  a  nearby  intes- 
tinal loop. 

Tlie  Results. — The  tendency  to  abandonment  of  this  somewhat  crude 
method  of  practice  is  not  yet  justifiable,  especially  since  it  is  evident  that  the 


Fig.  937.  Fig.  938.  Fig.  939. 

Fig.  937. — Artificial  anus  without  a  spur.     The  intestine  is  partially  opened  in  the  vicinity 

of  tlie  artificial  anus. 
Pig.  938. — Artificial  anus  with  spur.      The  afferent  and  elTerent  portions  of  the  bowel 

are  partially  opened. 
Fig.  939. — The  destruction  of  spur  by  enterotome.     Anterior  wall  of  the  intestine  cut 

away  to  show  better  the  position  of  enterotome. 

death  rate  attending  it  (8  to  9  per  cent)  is  nearly  IG  per  cent  less  than  that 
of  resection  of  the  bowel  for  cure.  Sixty  per  cent  are  cured  by  the  method, 
and  quite  30  per  cent  much  relieved. 

The  Geiieral  Remarls. — If  the  peritoneal  cavity  be  involved  in  the  opera- 
tion, failure  of  union  of  the  intestinal  opening  is  exceedingly  dangerous, 
especially  if  the  abdominal  wound  has  been  closed.  Therefore,  if  there  be 
reason  to  regard  union  as  at  all  problematical,  the  abdominal  wound  ought 
not  to  be  closed  entirely,  and  the  field  of  repair  should  be  carefully  isolated 
from  the  peritoneal  cavity  by  strips  of  iodoform  gauze.  If  the  colon  be  the 
intestine  involved,  lateral  approximation  (if  practicable)  is  the  best  method, 
for  then  serous  surfaces  only  will  be  in  juxtaposition.  End-to-end  union 
with  the  large  Murphy  button  or  by  Maunsell's  method  comes  next  in  order 
of  efficiency  in  the  majority  of  instances.  Direct  enterorrhaphy  is  less 
promptly  done,  because  the  exercise  of  vigilant  care  is  required  for  a  safe 
union  of  the  borders  of  gut  not  covered  with  serous  membrane,  and  defective 
repair  will  invite  prompt  and  fatal  disaster.  In  case  of  closure  of  intestinal 
openings  with  uncertain  outcome,  it  is  wiser  to  invert  the  edges  without 
trimming,  since  in  the  case  of  failure  the  opening  would  not  be  increased  in 
size.  The  introduction  into  the  fistulous  tract  of  a  catheter,  large  probe, 
gauze  packing,  etc.,  to  better  define  the  outline  during  the  removal,  is  a  com- 
mendable procedure.  R.  Morris  advises  the  employment  of  plaster  of  Paris 
for  the  purpose,  since,  when  introduced  in  a  plastic  condition,  it  fills  the 
inequalities  of  the  tract,  and  when  hardened  enables  the  surgeon  to  estimate 
its  limits  better  than  by  any  other  means.  Transverse  sewing  of  the  opening 
should  be  employed  if  possible,  in  lieu  of  the  longitudinal  variety,  when  the 
latter  reduces  unduly  the  lumen  of  the  gut.  The  detachment  of  the  parietal 
peritonaeum  in  this  operation  should  commence  at  the  distal  ends  of  the 


orKu.vrioNs  (»\  visci:ka  ('ONNPX"i'i;i)  wi'i'ii   imiki'I'ox.kim.    7:37 

incision  iiistcail  of  close  to  the  Wonlcr  of  the  fistula,  thus  i-cducin;,'  the  li;i- 
bility  of  o|tcninj^f  the  peritoneal  cuvity  to  a  niininiuin.  'I'iie  divided  tissues 
of  the  ahdoininal  wail  shoultl  he  closely  apposed  hy  sutures  to  eliminate  the 
occurrence  of  dead  spaces.  Tiie  presence  in  the  bowel  of  the  rubber  tube — 
for  tlie  purpose  of  lessening  the  spur  (Fig.  935),  and  perhaps  sufficiently 
diminishing  its  obstructive  influence  to  etfect  a  cure — is  attended  not  infre- 
quently by  a  nuirked  irritation  which,  on  removal  of  the  agent  for  two  or 
three  days,  (piickly  subsides. 

The  Aflcr-treatmoU. — As  fluid  food  only  is  given  for  two  or  three  days 
before  operation,  the  continuance  of  the  same  thereafter  for  a  brief  period 
is  a  valuable  element  of  treatment.  The  patient  is  kept  quiet  and  the 
wound  carefully  observed  after  the  third  day  for  the  presence  of  manifesta- 
tions of  failure  of  repair  in  order  to  antici[)ate  the  possibility  of  the  occur- 
rence of  fjecal  extravasation. 

Tlie  JicsuUs. — Failure  of  the  attempt  at  closure  of  fistuhi3  is  not  infre- 
quent, consequently  an  indulgence  in  glowing  prognosis  should  be  avoided. 
The  death  rate  in  simple  cases  should  be  insignificant  if  the  aseptic  and 
other  technique  be  supplemented  with  proper  post-operative  vigilance. 
Makins  reports  a  death  rate  of  38.4  per  cent  from  thirty-nine  cases  of 
resection  for  the  cure  of  fsecal  fistula.  About  10  per  cent  less  than  the 
above  now  conforms  more  nearly  to  the  operative  results. 

The  operations  connecting  the  intestine  with  the  stomach  {gastro-en- 
terostomy),  with  the  gall  bladder  {clioUcystenterostomij),  with  the  ureter 
[uretero-enterostomy),  etc.,  are  noted  elsewhere  under  more  significant 
headings. 

THE    OPERATIONS   ON   THE    STOMACH. 

It  is  necessary  sometimes  to  open  the  stomach  to  remove  foreign  bodies^ 
to  supply  nutrition,  to  overcome  oesophageal  obstruction,  or  to  remedy  the 
various  other  conditions  of  a  surgical  nature  that  are  amenable  to  inter- 
ference through  direct  incision  of  the  stomach.  In  each  instance  the  open- 
ing in  the  abdomen  and  the  viscus  is  made  as  small  as  may  be  consistent 
with  the  proper  operative  technique.  It  follows,  therefore,  that  the  digital 
sense  is  of  great  practical  utility  in  the  determinative  and  diagnostic  elements 
of  the  procedure.  The  finger  should  be  educated,  by  repeated  lessons  on  the 
dead  subject,  to  recognize  the  individual  characteristics  of  the  respective  tis- 
sues involved  in  the  operation,  their  relations  with  each  other,  and  the  pres- 
ence of  tangible  evidences  of  disease  complications,  without  unnecessary  delay 
or  harmful  manipulation. 

TJie  Anatomical  Points. — Whether  or  not  the  stomach  be  collapsed  or 
distended,  or  be  influenced  by  the  respiratory  acts  or  the  effects  of  disease, 
determines  very  largely,  indeed,  its  relations  with  the  associated  organs  and 
tissues.  When  empty  it  lies  posteriorly  and  beneath  the  liver  and  at  a  con- 
siderable distance  from  the  abdominal  wall  in  front,  and  upon  the  transverse 
mesocolon,  which  separates  it  from  the  pancreas,  the  large  abdominal  ves- 
sels, and  the  solar  plexus  (Fig.  940).  With  increasing  distention  the  ante- 
rior wall  looks  upward,  the  posterior  downward,  and  finally  the  former  rests 


1^38 


OPERATIVE   SURGERY. 


asainst  the  abdominal  wall  in  front.  In  the  normal  state  the  cardiac  orifice 
is  close  to  the  chondro-sternal  junction  of  the  left  seventh  rib.  An  empty 
pylorus  lies  about  three  inches  below  this  articulation  and  at  the  right  of  the 
linea  alba ;  when  distended  it  is  two  or  three  inciies  farther  to  the  right.  A 
triangle  formed  at  the  right  by  the  edge  of  the  normal  liver,  at  the  left  by 
the  free  borders  of  the  eighth  and  ninth  costal  cartilages,  with  its  base  at  a 
line  extending  between  the  tips  of  the  tenth  costal  cartilages,  corresponds  to 
the  surface  of  a  moderately  distended  stomach  lying  immediately  beneath 
the  abdominal  wall,  at  which  time  the  greater  curvature  lies  quite  near  to  the 

transverse  colon,  and  each  has 
been  mistaken  for  the  other  in 
operative  practice  (Fig.  94^). 
The  position  of  the  stomach  is 
changed  by  respiration,  de- 
scending with  the  inspiratory, 
and  ascending  with  the  expir- 
atory, act. 

TJie  identity  of  the  stomach 
is  established  by  its  immediate 
relation  with  the  under  surface 
of  the  liver  and  the  continuity 
with  the  anterior  layer  of  the 
gastro  -  hepatic  omentum  ;  by 
its  broad,  smooth  surface,  pale 
color,  dense  structure,  and  the 
characteristic  arrangement  of 
the  vascular  supply.  It  is 
placed  obliquely,running  down- 
ward from  left  to  right  in  the 
adult,  and  almost  vertically  in 
early  life. 

Gastrotomy.  —  The  opera- 
tion of  gastrotomy  contem- 
plates the  temporary  opening 
of  the  stomach  for  the  removal 
of  foreign  bodies,  for  pyloric 
and  oesophageal  exploration, 
and  for  other  measures  intended  to  determine  the  presence  of  pathological 
states  that  may  be  amenable  to  prompt  surgical  remedy. 

The  Prejxiratory  Treatment. — The  general  condition  of  the  patient 
should  first  be  fitted  for  the  operation  by  the  employment  of  remedies, 
when  the  benefit  to  be  gained  thereby  is  regarded  an  adequate  recompense 
for  the  delay  in  operative  procedure.  Usually,  however,  the  effects  of  pro- 
crastination are  so  well  marked  already  when  the  jiatient  comes  under  the 
observation  of  the  surgeon,  as  to  demand  prom])t  action  if  a  favorable  out- 
come is  to  be  expected.  If  there  be  no  obstacle  to  the  measure,  the  stomach 
should  be  thoroughly  washed   out  with  a  solution   of  liicarbonate  of  soda 


Fig.  940. — The  relations  of  the  stomach,  etc.,  to  the 
peritoniruiii  and  contiguous  oi'gans.  a.  Gastro- 
liepatic  or  lesser  omentum,  h.  Lesser  perito- 
neal cavity,  c.  Greater  peritoneal  cavity,  d. 
Folds  of  great  omentum,  e.  Small  intestines. 
/.  Liver,  g.  Coeliac  axis.  h.  Duodenum,  i. 
Transverse  mesocolon,  j.  Mesentery,  k.  Pan- 
creas.    I.  Foramen  of  Winslow. 


()|'K|{.\'ri()NS   ()\    VISCKI^A    ('oNNKCrill)    WITH    PKRITONyI':UM.     739 

boforc  the  ojjcnitioii.  Jf  the  or^aii  be  small,  it  may  he  (Iccmcd  iidvisable  to 
allow  live  or  six  ounces  of  tlio  (liiid  to  i-cmaiii,  thai,  the  location  of  the  stom- 
ach may  be  the  more  roiidily  determined.  However,  the  employtnent  of 
distend int!:  nieusures  of  any  kind  are  not  now  repirded  as  essential  or  even 
wise,  e.\ce[)t  in  special  cases,  as  they  may  prove  obstructive  and  even  disas- 
trous if  the  jjeritoneal  cavity  be  infected  by  their  incontinent  escape.  The 
intestinal  tract  should  be  thoroughly  cleansed,  espe(ually  the  large  intestine, 
to  fit  it  the  better  to  retain  nutritive  onemata.  Strict  asepsis  should  be 
exercised  in  connection  with  every  detail  of  the  operation. 

Chloroform  antvsthesia,  because  it  is  followed  by  nausea  and  vomiting  less 
frequently  than  ether,  is  preferable  in  operative  surgery  of  tlie  stomach,  unless 
special  objection  to  its  use  be  present.  After  proper  aniusthesia,  tlie  patient 
is  placed  on  the  back  with  the  legs  extended.  The  operation  field  is  pre- 
pared after  the  manner  before  stated  (page  008  et  seq.).  Local  anaesthesia 
from  cocain  should  be  used  instead  of  general  ana3sthesia  when  haste  or  great 
prostration  forbid  the  employment  of  the  latter. 

The  Operation  of  (rastrotoniy. — Make  an  incision  two  or  three  inches  in 
length  in  the  median  line  over  the  stomach  down  to  the  peritonaeum  (Fig. 
963) ;  arrest  hajmorrhage,  then  divide  the  peritonaeum  to  nearly  the  extent  of 
the  primary  incision  ;  grasp  the  borders  of  this  membrane,  draw  them  slightly 
upward  and  transfix  each  border  of  the  wound  through  the  entire  thickness 
with  a  curved  needle  armed  with  a  long  traction  suture ;  tie  a  single  fold  in 
each  suture,  thus  drawing  the  respective  tissues  of  each  border  of  the  wound 
in  contact  with  each  other ;  seize  the  ends  of  each  suture  independently  with 
a  forci pressure,  or  form  a  loop  of  each  by  tying  the  extremities  together ;  pull 
apart  the  borders  of  the  wound  by  means  of  the  traction  sutures ;  introduce 
the  index  finger  and  thumb  of  the  right  hand  into  the  wound  and  pass 
them  backward  along  the  under  surface  of  the  liver  to  the  gastro-hepatic 
omentum  (Fig.  940);  depress  the  hand,  thus  bringing  the  thumb  and 
finger  in  contact  with  the  upper  surface  of  the  stomach,  which  is  recognized 
by  the  broad,  smooth  surface  and  its  contiguity  to  the  liver  (Fig.  942)  ; 
seize  the  viscus  near  the  lower  border  with  the  thumb  and  fingers  and 
draw  the  anterior  wall  well  up  into  the  wound  ;  make  sure  that  the  stomach 
has  been  seized  by  ocular  examination.  Cause  the  assistant  to  seize  the 
stomach  at  either  side  of  the  abdominal  wound  with  the  thumb  and  fingers ; 
carefully  introduce  between  the  protrusion  and  the  borders  of  the  abdominal 
wound  fine  sponges  to  which  long  strings  are  tied  for  identification ;  supple- 
ment the  sponges  with  aseptic  gauze,  wet  with  saline  solution  if  advisable  ; 
pass  a  traction  suture  of  silkworm  gut  deeply  into  the  wall  of  the  stomach  at 
either  side  of  the  line  of  proposed  incision  ;  make  an  opening  two  inches  in 
length  into  the  stomach  in  the  vertical  axis  parallel  with  the  vessels  (Fig. 
942)  ;  raise  the  opening  still  farther  upward  by  means  of  the  traction  sutures, 
aided  by  small  retractors  if  necessary,  and  arrest  hajmorrhage.  If  the  stomach 
have  not  been  washed  out  and  the  need  for  it  be  present,  turn  the  patient 
carefully  to  the  right  side  so  as  to  allow  the  contents  to  escape,  directing 
them  away  from  the  patient  by  oiled  silk  or  abundant  gauze.  Finally,  flush 
the  stomach  with  hot  sterilized  water  or  a  bicarbonate-of-soda  solution,  if 
53 


740 


OPERATIVE  SURGERY. 


requisite  for  furtlier  cleanliness  or  better  technique.     Carefully  cleanse  the 
parts  and  draw  the  lips  of  the  incision  in  the  stomach  together  by  crossing 


Fig.  041. — Inslruinents  employed  in  gastrotoiny  and  gastrostomy. 

a.  Scalpels,  b.  Bistouries,  c.  Forcipressure.  d.  Curved  and  straight  scissors,  e.  Tluunb 
forceps.  /.  Xeedle-holdor.  h.  Retractor.  /.  Sponge-holder.  /.  Tenaculum,  k. 
Round  straight  needles  armed  wi(h  black  silk,  also  curved  needles.  /.  Traction  loops. 
m.  Silk  and  catgut  sutures,  n.  Sponge  with  string  attachment,  o.  Large  and  small 
gauze  pads  with  tape  attachments  and  forcipressure  anchor  of  pad.  Perforated  rub- 
ber dam  for  isolation  is  employed  (Turck). 


the  traction  sutures ;  renew  the  sponsre  and  gauze  packing  if  need  be,  and 
return  the  patient  to  the  dorsal  position.     Introduce  the  index  finger  care- 


OPERATIONS   ON   VISCERA    CONNKC'I'KD    WI'I'II    I'KRITONJ-^UM.     74I 

fully  into  the  stoiiiiich  and  search  Tor  and  locate  the  cause  deniaiidin^f  the 
operation,  enlarginjif  the  gastric  wound  sufficiently  to  admit  the  thumb  and 
oven  the  etitire  hand  if  needful  for  complete  examiiuition. 

Tlie  lii'Diitrks. — If  tlu^  exploration  he  for  the  purpose  of  overcoming 
obstrut'tion  at  the  pyloric  oi'  tlu^  car(lia(;  orifice,  or  for  the  removal  of  a 
foreign  body  by  way  of  either  of  these  oi)enings,  or  from  the  stomach  itself, 
the  stei)s  necessary  for  the  attainnient  of  the  object  are  carried  into  effect 
with  caution,  to  avoid  needless  injury  of  the  viscus  and  of  the  borders  of  the 
wound.  Therefore,  the  location  of  the  abdominal  incision  should  be  varied 
to  conform  with  the  requirements  of  the  case.  As,  if  examination  of  the 
cardiac  opening  of  the  o'sophagus  (page  593  et  seq.)  or  the  cardiac  end  of 
the  stomach  be  intended,  the  primary  incision  should  be  made  in  the  same 
direction  but  somewhat  farther  from  the  ribs  than  for  gastrostomy.  The 
pyloric  opening  and  other  portions  than  the  cardiac  can  be  properly  ap- 
proached through  the  median  incision  already  described.  Large,  fixed,  and 
rigid  foreign  bodies  discernible  by  external  manipulation,  or  by  the  X  rays, 
are  often  better  removed  through  an  external  incision  made  directly  upon 
them  than  through  either  of  those  just  described.  If  a  foreign  body  be 
present,  it  should  be  sought  for  first  at  the  pyloric  end  of  the  organ,  owing 
to  its  dependent  position,  and,  when  located,  seized  with  forceps  and  removed 
cautiously  with  due  resjject  for  the  injury  it  may  inflict  on  withdrawal.  It 
is  better  practice  to  increase  the  size  of  the  stomach  incision  so  as  to  allow 
easy  removal  than  to  bruise  the  tissues  by  forced  action.  If  the  examination 
is  for  disease  of  the  stomach,  the  borders  of  the  wound  should  be  opened 
widely  by  the  traction  sutures  and  retractors,  after  which  the  walls  of  the 
cavity  of  the  viscus  can  be  readily  inspected  in  detail  when  separated  by 
small  sponges  on  holders,  aided  by  a  strong  concentrated  light  (Fig.  681,  0). 
The  wound  in  the  stomach  is  closed  by  sewing  together  the  mucous  borders 
with  a  continuous  fine  silk  suture,  followed  by  union  of  the  remaining  coats 
with  interrupted  or  continuous  sutures  of  similar  material.  Even  a  third 
row  of  silk  sutures  should  be  added  if  any  doubt  of  security  be  present. 
After  thorough  cleansing  with  the  saline  solution,  the  traction  sutures  are 
removed  and  the  stomach  is  allowed  to  fall  back  into  place.  The  abdominal 
wound  is  then  closed  by  means  of  tier  suturing  (Fig.  779)  or  otherwise.  In- 
cisions for  exposing  the  stomach  should  not  be  vertical,  except  when  made 
in  the  median  line,  for  when  vertical  incisions  are  located  elsewhere  the  fila- 
ments of  the  abdominal  nerves  are  divided,  and  this  is  followed  by  loss  of 
power  of  the  muscular  structures  to  which  they  are  distributed. 

The  After-treatment. — The  patient  should  be  kept  quiet  and  sustained 
by  nutrient  enemata  for  the  first  few  hours.  Light  fluid  food  is  then  given 
in  small  amounts  at  frequent  intervals  for  two  or  three  days,  followed  soon 
by  simple  though  easily  digestible  food  of  a  more  substantial  nature. 

Tlie  Eesults. — About  20  per  cent  die  from  the  operation  of  gastrotomy. 
The  conditions  demanding  the  operation  contribute  much  more  to  the  fatal 
results  than  does  the  operation  itself. 

Gastrostomy. — The  operation  of  gastrostomy  signifies  the  establishment 
of  a  fistula  leading  from  the  stomach  to  the  external  world  for  the  j)ur2:)ose 


Y42 


OPERATIVE  SURGERY. 


of  preventing  starvation.  Gastrostomy  is  practiced  with  strict  aseptic  pre- 
cautions. The  employment  of  nutritive,  stimulating  enemata  should  precede 
for  a  longer  or  shorter  time  the  performance  of  the  operation.  Too  often 
the  favorable  opportunities  afforded  by  surgical  intervention  in  these  cases 
have  been  greatly  impaired  or  apparently  already  sacrificed  by  irrational 
delay  before  the  surgeon  is  consulted.  In  such  cases  as  these  complicated 
surgical  effort  under  general  anesthesia  is  quite  surely  fatal.  Therefore, 
local  anaesthesia,  attended  by  simple  operative  practice,  should  be  employed, 
or  tubage  (page  005)  utilized  instead,  as  may  seem  wisest  at  the  time.  In 
any  event,  local  Avarmth  should  be  provided  and  general  stimulation  practiced 
before  the  operation  is  commenced.  The  instruments  required  differ  in  no 
special  regard  from  those  for  gastrotomy  (Fig.  941). 


Pig.  943. — The  anterior  surface  of  the  stomach,  showing  its  relation  to  the  liver,  the 
transverse  colon,  the  great  omentum,  and  the  cartilages  of  the  ribs.  a.  Gastro-epi- 
ploica  sinestra  artery,  b.  Gastro-epiploica  dextra  artery,  c.  Small  intestines,  d. 
Caecum,     e.  Ascending  colon.     /.  Gall  bladder,    g.  Sigmoid  flexure. 


Stages  of  tlie  Operation. — The  operation  may  be  completed  at  one  sitting 
or  divided  into  two  stages  (Ilowse),  according  to  the  nutritive  demands  of 
the  case  or  the  special  method  of  procedure  adopted.  In  either  instance  it 
can  be  divided  into  the  following  steps  :  1,  The  locating  and  making  of  the 
abdominal  incision ;  2,  the  exposing  and  drawing  into  the  abdominal  wound 


oi'KijA'i'ioNs  ON  \is('ki;a  cunxkc 'ti:i)  wi'i'ii  1'i:kitonm:um.    743 

of  tlie  rc'(iuisite  })orliuu  of  tlie  .stuiiuicli  ;  ;],  the  lixaticjii  and  opening  of  the 
stoniaeh. 

Tlic  First  Step  {fjorah'iir/  and  Afdkin;/  A/f</oi/iinal  J/irisioii). — Locate  tlie 
free  margin  of  the  liver  and  the  costal  cartilages  of  the  eighth  and  ninth 
ribs  on  the  left  side;  make  an  oblique  incision  two  inches  and  a  half  in 
length  with  the  center  an  inch  below  the  free  margin  of  the  liver  (Fig.  9C;3) 
parallel  with  and  an  inch  and  a  half  inside  the  b(M-ders  of  the  costal  carti- 
lages of  the  eighth  and  ninth  ribs  down  to  the  external  oblique  muscle  (Fig. 
94'i) ;  divide  the  fibers  of  the  external  oblique,  separate  those  of  the  internal 
and  hold  them  ajiart  with  blunt  retractors  ;  divide  the  fibers  of  the  trans- 
versalis  muscle,  thus  reaching  the  transvcrsalis  and  subserous  fasciti?,  which 
are  then  likewise  cut.  Arrest  hivmorrhage,  pick  up  the  peritouieum  with 
forceps,  and  carefully  divide  it  to  an  extent  similar  to  that  of  the  other  tis- 
sues. Introduce  traction  sutures  entirely  through  each  border  of  the  wound, 
and  tie  and  loop  as  before  described  (page  739). 

T/ie  Iieniarks. — Since  this  class  of  patients  is  usually  very  much  emaci- 
ated, the  tissues  to  be  divided  are  naturally  inclined  inward  and  downward 
from  the  free  borders  of  the  cartilages  of  the  ribs,  therefore  the  edge  of  the 
knife  should  be  turned  backward  and  a  little  outward  to  secure  a  proper 
division  of  the  respective  structures.  This  incision  sometimes  involves  the 
sheath  of  the  rectus  muscle  and  perhaps  the  muscle  itself.  In  the  latter 
instance  the  fibers  can  be  cut  or  pulled  aside  as  seems  best  at  the  time. 
Jacobson  prefers  a  vertical  incision  made  from  a  point  opposite  the  inner 
end  of  the  eighth  intercostal  space  (Fig.  9G3)  downward  for  three  inches 
parallel  with  and  about  two  inches  to  the  outer  side  of  the  linea  alba.  The 
fibers  of  the  rectus  abdominis  are  exposed  and  separated  without  division, 
the  posterior  layer  of  the  sheath  is  divided  vertically,  the  borders  of  the 
wound  are  separated  and  the  fascia?  and  peritonteum  divided  as  before. 

Tlte  Second  Step  {Exposing  and  Drawing  Part  of  Stomach  into  Wound). 
— Draw  apart  the  borders  of  the  wound  with  the  traction  sutures,  aided  by 
blunt  retractors  if  necessary,  bringing  the  lower  border  of  the  liver,  and 
perhaps  the  stomach,  into  view  ;  pass  the  index  finger  backward  along  the 
under  surface  of  the  liver  to  define  the  stomach,  if  not  already  apparent ; 
seize  and  draw  the  stomach  forward  and  locate  the  best  point  for  the  open- 
ing. In  determining  this  fact,  remember  that  the  opening  should  be 
located  as  near  to  the  greater  curvature  and  the  cardiac  end  as  is  possible 
consistent  with  the  integrity  of  the  vascular  supply  (Fig.  987).  Entire  free- 
dom from  needless  traction  on  the  organ  after  its  union  with  the  abdominal 
wall  should  also  be  secured.  Having  fixed  on  the  point  of  opening,  seize 
the  wall  at  that  point  with  forceps,  and  draw  into  the  wound  the  necessary 
amount  of  the  viscus  to  conform  to  the  requirements  of  the  method  of 
operation  adopted. 

The  Remarks. — The  stomach  may  be  mistaken  for  the  transverse-  colon 
(Fig.  942),  especially  when  the  former  is  much  contracted,  or  when  the  latter 
promptly  presents  at  the  wound.  However,  the  ditferences  in  the  color, 
density,  smoothness,  omental  connections  and  relation  with  the  liver,  should 
promptly  prevent  the  possibility  of  error  in  this  respect.     Often  the  great 


744  OPERATIVE  SURGERY. 

omentum  Avill  appear  at  the  wound,  and  especially  if  the  colon  be  drawn 
upward  by  retraction  of  the  stomach  or  the  manipulations  of  the  o])erator. 
If  the  stomach  be  unusually  small,  or  have  become  contracted  from  the 
effects  of  disease,  or  be  adherent  posteriorly,  much  difficulty  may  be  ex- 
perienced in  properly  connecting  it  with  the  external  opening.  As  soon 
as  the  abdomen  is  opened,  the  entrance  of  air  often  causes  abdominal  dis- 
tention and  also  the  retreat  of  the  stomach  backward  beneath  the  liver,  thus 
adding  an  impediment  to  the  bringing  forward  of  the  viscus. 

Tlie  Tliird  Step  {Fixatioti  and  Opening  of  the  Stomach). — Draw  the  stom- 
ach forward  into  the  wound  sufficiently  to  form  a  neck  at  that  situation  of 
about  three  fourths  of  an  inch  in  diameter ;  transfix  the  extremities  of  the 
abdominal  wound  with  silkworm-gut  sutures  carried  through  the  whole  thick- 
ness of  the  abdominal  wall ;  unite  the  neck  of  the  protrusion  with  the  borders 
of  the  abdominal  wound  by  means  of  several  silkworm-gut  sutures  carried 
through  the  serous  and  muscular  coats  of  the  former,  thence  outward  through 
the  entire  thickness  of  the  abdominal  wound,  by  a  curved  needle ;  pass  a 
guiding  suture  through  the  apex  of  the  protrusion,  tie  the  sutures  at  either 
end  of  the  wound,  thus  fixing  the  protrusion  in  a  secure  position ;  dust  the 
wound  and  the  protrusion  with  iodoform,  apply  protective  dressings,  put  the 
patient  in  bed,  providing  for  comfort  and  proper  nutrition,  thus  ending  the 
technique  of  the  first  stage  if  the  operation  is  to  be  thus  divided.  If  not,  an 
opening  is  made  into  the  stomach  at  once  instead  of  after  two  or  three  days' 

delay,  remembering  that  if  the  opening  be 
made  too  near  the  pyloric  end  of  the 
stomach,  regurgitation  of  food  may  result. 
The  Remarks. — Additional  security  is 
gained  by  the  use  of  fine  sutures  between 
the  preceding  ones,  uniting  the  wall  of 
the  protrusion  and  the  border  of  the 
wound  with  each  other  somewhat  super- 
ficially. If  time  will  jiermit,  the  outer 
coat  of  the  jirotrusion  can  be  united  by 
means  of  a  primary  row  of  continuous  or 
interrupted  silk  or  catgut  sutures  with 
the  bordej'S  of  the  divided  jaeritonffium. 
However,  here  as  elsewhere,  about  the 
abdominal  cavity,  the  parts  when  thus  ar- 
ranged in  the  opening  are  less  securely 
a  fixed  than  when  joined  directly  with  the 

Pig.  948.— The  fixation  of  the  stoinat-h     borders   of    the    wound.       The    modified 
in   e-astrostomy,   Howse's    nietliod,  ,  ^     tt  ■  t    t    ^       r^      • 

first  step.  suture   of    Howse   is   regarded    by  (ireig 

Smith  as  being  the  most  secure  for  the 
purpose  (Fig.  943).  It  is  applied  as  follows  :  Introduce  two  silver-wire  loops 
near  the  site  of  the  proposed  opening  (a,  a)  in  the  stomach,  to  afford  ease  in 
manipulation  of  it  during  sewing  ;  convey  a  needle  armed  with  a  soft  silk 
ligature  {h)  about  a  foot  in  length  around  the  base  of  the  protrusion  beneath 
its  serous  and  muscular  coats,  inserting  it  and  causing  it  to  emerge  succes- 


tJl'lIliATlONS   O.N    NISCKKA    C'U.N.NKCTKD    WITH    i'EiilTUN J;L'M.     745 


sively  so  as  to  form  loops  about  an  inch  and  a  half  in  length,  situatt-d  at 
about  half-incii  intervals,  until  six  or  eight  loops  are  made,  taking  care  to 
cause  a  crossing  of  the  suture  at  the  base  of  each  loop,  as  iiulicated  in  the 
illustration.  Then  transfix  the  border  of  the  wouiul  at  sites  opjxjsite  to  the 
loDps  with  liduknl  needles,  by  means  of 
which  the  loops  are  drawn  through  the  skin 
and  are  then  fasteiu'd  in  })lace  l)y  rubber 
tul)iug  slipped  beneath  them.  Fix  the 
loops  tlrmly  to  the  tubing  by  drawing  uj)on 
and  tying  the  loose  entk  of  the  suture; 
bend  the  ends  of  the  silver  wire  around 
the  tubing,  thus  holding  the  stomach  up- 
ward into  the  wound  (l''ig.  944).  Harelip 
pins,  long  needles,  anil  temporary  sutures 
of  silkworm  gut  can  also  be  used  for  the 
purpose. 

The  latter  part  of  the  third  step — open- 
ing the  stomach — can  be  practiced  at  once, 

or  deferred  {second  siar/e),  according  to  the  Fio.  944.— The  fixation  of  the 
,  1        e    .^  T         -ji  •      ,  stomach  in  Erastrostoiiiv.  llowses 

demands  of  the  case.     In    either   instance  method,  fixation  fompleted. 

the  point  for  opening  is  raised  up  by  means 

of  the  guiding  sutures  or  the  forceps,  and  an  incision  large  enough  to  admit 
snugly  a  rubber  tube  of  the  size  of  a  No.  8  or  No.  10  Eng.  catheter  is  made 
into  the  stomach  with  the  end  of  a  sharp-pointed  bistoury.  The  tube  should 
be  freely  flexible,  about  eighteen  inches  in  length,  and  provided  with  a  small 
funnel  for  feeding  the  jjatient.  The  cautery  is  sometimes  employed  in  open- 
ing the  stomach,  but  has  nothing  to  commend  it  except  the  prevention  of 
hfemorrhage,  whicli,  with  proper  care,  is  so  insignificant  and  so  readily 
arrested  as  not  to  be  of  serious  import. 

The  Remarks. — If  the  making  of  the  opening  be  deferred  for  four  or 
five  days,  firm  adhesions  will  have  taken  place  between  the  stomach  and 
borders  of  the  wound,  and  leakage  into  the  peritoneal  cavity  need  not  be 
regarded  as  possible.  A  troublesome  cough  is  a  contraindication  to  the 
operation. 

Hie  After-treatment. — The  character,  amount,  and  i)lan  of  administra- 
tion of  nutrition  by  the  rubber  tube  differs  in  no  essential  regard,  after  a 
little  time,  from  that  by  means  of  the  normal  esophageal  tube,  except  that 
the  quantities  introduced  are  smaller,  more  finely  divided,  and  more  fre- 
quently given  for  obvious  physiological  reasons.  Koumiss,  peptonized  milk, 
with  eggs,  brandy,  etc.,  can  be  given  at  first  frequently  and  in  small  amounts 
{half  an  ounce  or  so),  and  gradually  increased  as  the  case  progresses.  The 
mastication  of  food  by  the  patient  before  its  discharge  through  the  tube  into 
the  stomach  adds  to  the  act  the  pleasure  of  gustation  and  to  the  food  the 
digestive  influence  of  the  saliva  (Fig.  945). 

The  Precautions. — The  food  should  be  strained  to  prevent  blocking  the 
tube,  and  be  given  at  the  temperature  of  the  body.  If  regurgitation  hap- 
pen  the  patient  should  lie  on  the  back  during  the  administration  of  food. 


746 


OPERATIVE   SURGERY. 


In  the  interim  of  feeding,  tlie  tube  is  fastened  against  the  abdomen  in  the 
form  of  a  coil,  with  the  open  end  surrounded  with  absorbent  gauze  to  permit 
the  ready  escape  of  the  fluids  and  gases  through  the  tube,  when  necessary, 
rather  than  through  the  opening  by  the  side  of  the  tube.     The  tube  should 

be  kept  clean  and  changed  often  enough 
to   preserve  its  sanitary  condition   and 
structural   integrity.     The   free   use   of 
vaseline    after    washing  the   surface  of 
the  abdomen  with  limewater  and  asep- 
tic solutions  will  reduce  the  annoyance 
from   contact  with    gastric   fluids   to 
a  minimum.      The 
opening   of    an   es- 
tablished  fistula   is 
closed   with   a   pad 
of    non  -  absorptive 
material    after     re- 
moval of    the  tube 
in  feeding. 

The  Results.— 
According  to  Gross, 
the  rate  of  mortal- 
ity as  based  on  207 
cases  is  29.47  per 
cent.  In  1G2  cases 
Zesos  estimated  it  at  GO  per  cent  in  cicatricial  and  84  per  cent  in  malignant 
stenosis.  When  it  is  considered  that  the  latter  observer  dealt  with  cases 
treated  under  antiseptic  technique,  it  is  apparent  that  a  fallacy  in  reasoning 
exists  in  one  or  the  other  conclusions  of  these  surgeons.  Later  estimates 
place  the  rate  of  mortality  at  about  28  per  cent  in  malignant  cases,  and  at 
about  19  per  cent  in  non-malignant. 

Witzel's  Method. — WitzeFs  method  is  one  especially  directed  to  tlie  estab- 
lishment of  a  canal  or  pseudo-oesophagus  along  the  wall  of  the  stomach, 
which  is  much  better  suited  to  prevent  the  escape  of  the  contents  of  the 
stomach  through  the  abdominal  opening  than  is  the  preceding  method. 

llie  abdominal  incision  is  made  at  the  left  side  and  at  the  place  best 
suited  to  the  practice  of  the  surgeon  or  the  demands  of  the  case.  Usually 
it  is  made  about  three  inches  in  length,  beginning  near  the  median  line  and 
passing  obliquely  downward  and  outward  across  the  rectus  abdominis  par- 
allel with  and  an  inch  to  an  inch  and  half  below  the  borders  of  the  costal 
cartilages  (Fig.  963).  The  muscular  fibers  of  the  rectus  abdominis  are  dif- 
ferently treated  in  the  course  of  the  incision.  They  can  be  divided  obliquely, 
separated  vertically  (Von  Hacker),  or  folds  of  muscle  can  be  caused  to  cross 
each  other  from  either  side  of  the  line  of  separation  between  which  the  wall 
of  the  stomach  is  drawn  up  (Girard).  In  the  last  two  examples  the  forma- 
tion of  a  sphincter  to  control  the  opening  is  aimed  at,  and  in  the  majority 
of  instances  with  beneficial  results.     The  stomach  is  drawn  into  the  wound 


Fig.  945. — Patient  feeding  himself  through  a  gastric  fistula. 


UPHKATIONS   ()\    VlSCHilA    CONN'KCTKl)    WITH    i'KUlTUN .KUM.     747 


sufficiently  to  permit  full  scope  for  the  necessary  manipulutions,  and  tlie 
borders  of  the  wound  are  i)acked  witli  gauze.  A  small  opening  is  then 
made  into  tiie  stomach,  directed  io\v;ird  tlie  cardiac  end,  of  sufficient  size 
to  admit  somewhat  snugly  the  end  of  a  ru})l)('r  tul)e  (size  2o  French),  of 

whicli  ahiiut  an  inch  is  introduced  and 
the  external  jjortion  is  pressed  upward 
against  the  stomach  parallel  with  the 
borders  of  the  abdominal  incision,  and 


t     ,.    'HmH,-¥,4^ 


\     ';■ 


Fiu.  'J4(). 


Fig.  947. 


:V 

Fig.  948.  Fig.  949.  Fig.  950. 

Fig.  946. — Witzel's  iDOthod  of  gastrostomy,  wrapping  in  tlie  tube. 
Fig.  947. — Witzel's  method  of  gastrostomy,  the  tube  wrapped  in. 
Fig.  948. — Witzel's  method  of  gastrostomy,  the  stomach  sutured   in   place  and  sutures 

laid  to  close  the  abdominal  wound. 
Fig.  949. — Witzel's  method  of  gastrostomy,  the  abdominal  wound  closed  and  the  tube 

constricted  above. 
Fig.  950. — Witzel's  method  of  gastrostomy,  a  longitudinal  view  explaining  the  relation 

of  the  tube  to  the  arrangement  of  the  parts. 

wrapped  in  for  two  or  three  inches  of  its  length  by  uniting  the  walls  of  the 
stomach  over  it  with  several  silk  Lembert  sutures,  fortified,  if  need  be,  by 
a  continuous  row  thereafter  (Figs.  940  and  94T).     The  stomach  is  allowed 


us 


OPEKATIVE   SUIIGKRY. 


to  retreat  sufficiently  to  permit  the  entire  operation  field  to  present  at  the 
wound,  when  its  borders  are  closely  united  to  the  ])eritonanun  and  posterior 
layer  of  the  sheath  of  the  rectus  by  interrupted  silk  sutures  (Fil,^  948). 
The  abdominal  wound  is  then  completely  united  by  interrupted  silkworm- 
gut  sutures,  and  the  tube,  closed  above  by  tying,  or  by  a  rubber  band 
(Fig.  949),  is  fastened  in  position  by  a  stitch.  The  tube  is  kept  in  place 
for  three  or  four  days  until  firm  adhesions  have  ensued,  the  patient  being 
nourished  with  nutritive  enemata.  After  this  time  the  patient  is  fed  through 
the  tube,  which  is  at  first  introduced  at  frequent  intervals  to  prevent  undue 
closure  of  the  opening.  Later,  however,  the  tube  is  employed  only  for  the 
purpose  of  feeding ;  unless,  as  sometimes  happens,  the  difficulty  of  reintro- 
duction  (Fig.  950)  makes  necessary  permanent  retention. 

The  Results. — While  the  special  benefits  attributed  to  this  method  are 
not  always  realized,  still,  the  outcome  compares  favorably  with  that  of  other 
measures. 

Ssabanejew-Franck  Method. — Kocher  credits  Albert  with  this  method, 
and  regards  it  as  being  "  the  simplest  and  most  reliable  "  one  as  modified  by 
himself.      Kocher  carries  the  abdominal  incision  downward  and  outward 


-./      \ 


Fig.  951.  Fig.  952. 

Fig.  951. — Ssabanejew-Franck  method  of  gastrostomy,  stomach  drawn  into  the  wound 

and  sutured  in  place. 
Fig.  952. — Ssabanejew-Fi-anck  method  of  gastrostomy,  the  lower  wound  closed  and  the 

borders  of  the  opening  stitched  to  those  of  the  upper  incision. 

over  the  rectus  muscle — more  vertically  than  horizontally — about  two  inches 
from  the  margin  of  the  costal  cartilages  ;  the  muscular  fibers  of  the  rectus 
are  separated  vertically  at  the  inner  edge  of  the  wound  and  di-awn  apart; 
the  posterior  wall  of  the  sheath  of  the  rectus  and  the  periton;i3nm  are 
divided,  a  long  conical  process  of  the  stomach  is  drawn  into  the  wound, 
and  its  base  is  united  without  much  constriction  to  the  deep  borders  of  the 
wound  by  continuous  or  interrupted  sutures,  which  include  the  serous  and 
muscular  coats  of  the  stomach  on  the  one  side  and  the  peritonctum  and  pos- 


Ul'KKATlO.NS    UN    NISCIIKA    fO.NNKCTKD    WITH    J'llUI'I'ONMlLM.     74<j 

terior  ])iirt  of  tlio  slioiitli  of  tljo  recitus  on  tlio  other  (V\</.  !».")!).  The  foiiii- 
tlors  of  the  method  made  the  pi'iiiiiiry  incision  iiioi'e  ohii(|U(;,  ami  divided  in 
tlie  same  direct  inn  lihci-s  n\'  the  rectus  muscle  instead  of  separating  tiiein. 
A  small  incision  is  then  made  throu^di  the  skin  al)out  an  inch  aiiove  the 
cartilages  of  the  rihs,  tlir  iutci-veiiiug  hridge  of  skin  is  uiiih'i-mincd,  and  the 
apex  of  the  diverticulum  of  the;  stonuich  is  drawn  n|)\vai-d  under  the  skin 
and  over  the  lower  costal  cartilages  as  fur  us  the  small  skin  incision,  to  the 
edges  of  which  the  apex  is  fastened  by  sutures  (Fig.  953).  A  small  opening 
is  made  at  once  into  the  upex  of  the  protrusion,  additional  sutures  ui'c  intro- 
duced ut  the  borders,  und  the  lower  wound  is  closed  with  u  continuous  or 
interrupted  suture. 

77ie  lienutrkfi. — The  success  of  this  plan  requires  thut  tiie  stonuudi  be 
lux,  and  therefore  not  contracted  or  adherent,  as  it  is  liaV)le  to  be  from  the 
effects  of  the  various  causes  that  demand  gastrostomy,  and,  as  sometimes 
happens,  from  prolonged  starvation.  The  permanency  of  the  fistula  formed 
by  this  method  contraindicates  its  employment  in  cases  of  oesophageal  or 
gastric  disease  amenable  to  cure.  This  method  of  practice  is  hardly  possi- 
ble unless  at  least  an  inch  and  a  half  of  the  wall  of  the  stomach  can  be 
drawn  through  tlie  wound  (Keen).  The  bending  upward  of  the  diverticu- 
lum and  the  grasping  of  its  base  by  the  separated  fdjers  of  the  rectus  muscle 
(Fischer)  presents  the  escape  of  fluids  from  the  stomach  and  offers  no 
obstacle  to  their  introduction  with  u  catheter. 

Hahn's  Modification. — Ilalin  gained  access  to  the  stomach  by  means  of 
Fenger's  incision,  which  is  made  about  three  inches  in  length  and  locuted 
to  the  left  of  the  sheath  of  tlie  rectus  muscle,  parallel  with  and  about  an  inch 
below  the  costal  cartilages  (Fig.  963).  He  then  made  a  superior  incision 
through  the  eighth  intercostal  space  close  to  the  cartilages,  perforated  the 
intervening  tissues  with  sharp-pointed  haemostatic  forceps  guided  by  the 
finger  in  the  lower  wound,  seized  the  wall  of  the  stomach  with  the  forceps, 
drew  it  into  the  upper  incision,  joined  the  apex  to  the  skin  with  sutures,  and 
then  finally  closed  the  lower  opening  in  the  usual  way. 

The  Remarh>i. — Hahn's  modification  offers  no  especial  practical  advan- 
tages to  compensate  for  the  increased  danger  attending  its  employment. 
The  pleural  cavity  may  be  involved,  and  the  efforts  to  obviate  this  danger 
may  lead  to  injury  of  the  cartilages  and  their  subsequent  necrosis.  There 
is  no  reason  to  believe  that  the  restraining  influences  of  the  cartilages  are 
supei-ior  to  the  tissues  utilized  in  other  and  safer  plans  of  practice. 

Senn's  (E.  J.)  Method. — The  basis  principle  of  action  of  this  method  is 
the  formation  from  the  walls  of  the  stomach  of  a  circular  valvelike  structure 
near  the  surface,  which  readily  permits  of  the  introduction  of  food,  yet  aims 
to  prevent  the  escape  of  fluid  at  all  times. 

The  Operation. —  ■Make  the  abdominal  incision  at  the  most  desirable  situ- 
ation irrespective  of  the  muscular  structures,  as  their  action  is  not  needed  in 
this  method  ;  grasp  the  anterior  surface  of  the  stomach  near  the  greater 
curvature  with  the  fingers  or  a  suitable  forceps,  and  draw  a  cone-shaped 
])ortion  well  ujnvard  into  the  opening,  giving  it  in  charge  of  an  assistant; 
introduce,  so  as  to  include  the  serous  and  muscular  coats  of  the  stomach, 


150 


OPERATIVE   SURGERY. 


two  and  a  lialf  inches  below  the  apex  of  the  cone,  two  purse-string  sntures 
of  chroniicized  catgut  (Fig.  953) ;  draw  them  tightly,  thus  forming  a  neck 
(Fig.  954) ;  raise  up  a  portion  of  the  gastrocolic  omentum  and  suture  it  in 
a  culflike  manner  around  the  constriction  with  silk  (Fig.  955) ;  suture  the 

stomach  in  place  with  silk  so  as  to  in- 
clude its  serous  and  muscular  coats, 


Fig.  953.  Fig.  954. 

Fig.  953. — Senn's  method  of  gastrostomy,  the  purse-string  sutures  placed. 
Fig.  954. — Senn's  method  of  gastrostomy,  the  purse-string  sutures  drawn  tiglit. 


the  upper  portion  of  the  omental  cuff,  and  all  of  the  structures  of  the  bor- 
ders of  the  abdominal  wound  except  the  skin ;  close  the  skin  with  silkworm- 
gut  sutures,  leaving  in  sight  the  apex  of  the  cone  from  which  the  valve  is 
formed ;  make  an  incision  at  once,  or  later,  as  need  be,  about  an  inch  and  a 
half  in  length  in  the  center  of  the  exposed  portion,  and  introduce  through  it 
a  rubber  tube  into  the  stomach ;  invert  the  lips  of  the  incision,  and  unite 
with  eacli  other  the  corresponding  borders  with  silkworm  gut  in  such  a  man- 
ner as  to  form  a  valvelike  opening  not  more  than  half  an  inch  in  length 
(Fig.  956).     The  tube  is  employed  only  at  the  time  of  feeding.     This  method 


-^H. 


Fig.  955.  Fig.  956. 

Fig.  955. — Senn's  method  of  gastrostomy,  the  omental  cuflE  applied  and  sutured  in  place. 
Fig.  956. — Senn's  method  of  gastrostomy,  the  apex  of  cone  opened,  inverted,  and  sutured 
in  position. 


is  simple,  readily  and  rapidly  done,  obviates  leakage,  and  exposes  the  patient 
to  comparatively  little  danger. 

Kader's  Method. — Kader  was  prompted  to  supply  this  method  for  a  case 
not  amenable  to  other  plans  of  procedure  because  of  a  small  and  but  slightly 
movable  stomach.     The  plan  is  a  modification  of  Witzel's,  and  is  of  broader 


OrKRATIONS   ON    VISCERA   CONNECT  ED    WITH    PERITON.EL'M.     751 


application  becunso  of  the   difTerciicc  in  the  rehitions  of   the  tube  to  the 
stoinai'h. 


Fig.  957. 


Fi(i.  9o8. 


Fig.  957. — Kador's  method  of  gastrostomy.  Tube  in  place  and  fixed  by  suture  (a). 
b,  b,  b,  b.  Infolding  sutures,  c,  c.  Primary  transverse  folds  of  stomach,  d.  Inter- 
val between  folds. 

Fig.  958. — Kader's  method  of  gastrostomy.  Sutures  tieil,  ends  of  two  (a,  a)  left  long  for 
better  control,  supplemental  sutures  placed  at  either  end  of  infold. 

T/ie  Ope  rati  0)1. — Make  tlie  oblique  or  vertical  abdominal  incision,  as  suits 
the  fancy  of  the  operator  or  requirements  of  the  case ;  se])arate  the  fibers  of 
the  rectus  by  blunt  dissection,  and  divide  the  posterior  wall  of  its  sheath  verti- 
cally in  either  instance ;  draw  through  the  opening  a  fold  of  the  stomach  in 
the  usual  way,  if  its  size  and  mobility  will  permit ;  pack  the  field  with  gauze  ; 
make  a  small  incision  into  the  stomach  with  a  narrow  bistoury ;  introduce 
through  it  into  the  stomach,  for  two  inches,  the  end  of  a  rubber  tube  the  size 
of  a  pencil  (Fig.  957) ;  arrest  bleeding, 
and   fasten    the   tube  to   the  stomach  (|fc) 


Fig.  959.  Fig.  960. 

Fig.  959. — Kader's  method  of  gastrostomy,  a.  a,  a,  a.  Second  row  of  sutures  placed. 
b.  b,  b,  h.  Primary  row  to  be  covered  in.     d,  d.  Secondary  transverse  folds  of  stomach. 

Fig.  960. — Kailer's  method  of  gastrostomy,  second  row  of  sutures  tied  and  tube  protrud- 
ing inward  with  the  stonuich  wall. 

with  a  catgut  suture  {a) ;  introduce  at  either  side  of  the  tube  (r,  r),  so  as  to 
include  the  serous  and  muscular  coats  of  the  stomach,  two  silk  Lembert 


752  OPERATIVE  SURGERY. 

sutures  half  an  inch  apart  {h,  Z>,  b,  b),  so  placing  tliem  that  each  will  include, 
at  the  extremes  of  an  interval  of  three  fourths  of  an  inch,  half  an  inch  of 
corresponding  portions  {<l)  of  the  stomach  ;  tie  the  sutures  firmly  (Fig-  958), 
drawing  together  the  included  tissue  and  thus  forming  two  longitudinal 
folds ;  push  into  the  stomach  the  infolded  tissues,  causing  contiguous  serous 
membrane  to  come  in  contact  with  the  tube;  unite  togetlier  as  before  two 
additional  folds,  thereby  covering  in  the  preceding  ones,  and  thus  lengthen- 
ing the  canal  in  whicli  the  tube  yet  remains  (Fig.  959) ;  leave  the  sutures 
long  for  a  time  (Fig.  960),  thus  securing  better  command  of  the  stomach  ; 
stitch  the  stomach  to  the  denuded  borders  of  the  jjeritonaium  and  sheath  of 
the  rectus  simultaneously ;  close  carefully  the  external  wound  with  sutures. 

Stamm  formed  a  canal  of  the  wall  of  the  stomach  by  drawing  it  around 
a  catheter  introduced  vertically  into  that  organ  by  means  of  a  purse-string 
suture  carried  through  the  serous  and  muscular  coats  at  a  distance  of  about 
an  inch  from  the  catheter,  then  drawn  tightly  and  tied. 

TJie  Remarks. — If  the  stomach  can  not  be  brought  into  the  wound  on 
account  of  its  small  size  or  the  presence  of  adhesions,  deep  occlusion  sutures 
are  employed  to  draw  it  up  and  unite  it  to  the  opening,  thus  closing  the 
peritoneal  cavity.  If  this  measure  fails,  the  stomach  is  opened  in  the  abdomi- 
nal cavity.  Meyer  has  met  with  an  instance  of  this  kind.  Perpendicular 
folds  of  the  coats  of  the  stomach  should  be  formed  in  permanent  fistula ;  the 
transverse  in  the  temporary.  On  removal  of  the  tube  the  opening  is  guarded 
by  the  valvelike  infolding  of  the  stomach  wall. 

The  Results. — Thus  far  the  outcome  from  this  method  is  very  good.  In 
ten  cases  operated  on  by  Mikulicz  all  made  satisfactory  recovery. 

Andrew's  Method. — This  method  can  be  practiced  by  making  a  vertical 
incision  through  the  anterior  wall  of  the  stomach  two  inches  in  length, 
through  which  a  portion  of  the  wall  immediately  below  is  drawn  upward  and 
exposed,  with  the  mucous  membrane  uppermost.  The  tube  is  then  placed 
on  this  membrane  in  the  line  of  the  incision  into  the  stomach,  and  the  mem- 
brane only  is  divided  at  either  side  of  and  parallel  with  the  tube  at  such  a 
distance  that  the  strip  of  membrane  thus  formed  will  surround  the  tube 
when  its  borders  are  united.  The  distal  borders  of  this  incision  are  then 
brought  over  the  already  covered  tube  and  united  by  sutures.  The  gastric 
wound  is  closed,  the  stomach  connected  to  the  abdominal  wall,  and  the  exter- 
nal opening  closed  around  the  tube  in  the  usual  manner.  Practical  experi- 
ence in  the  use  of  this  method  is  required  to  establish  its  comparative  value 
and  freedom  from  seemingly  difficult  if  not  dangerous  operative  technique. 

Marwedel's  Method. — The  stomach  is  exposed  through  the  oblique  in- 
cision, united  to  the  abdominal  wound,  and  the  serous  and  muscular  coats 
are  divided  obliquely  for  about  two  inches  down  to  the  mucous  membrane, 
which  is  then  perforated  at  the  cardiac  end,  the  end  of  the  tube  inserted 
into  the  stomach  (Fig.  961),  and  the  remainder  covered  over  by  union  of  the 
borders  of  the  serous  and  muscular  coats  with  a  buried  suture,  and  the  ex- 
ternal wound  is  closed  (Fig.  962). 

The  Results.— The  results  thus  far  (five  in  number)  are  flattering— four 
recovered,  and  one  died  on  the  following  day  from  the  effects  of  inanition. 


OIM:i;A'I"I()\S   ox    VISCKIIA    COyNECTED    with    I'Hin'I'ONMlL^M.     753 

The  rlioicc  of  opcrtttidii  will  (Icpciid  vrry  much,  iiuk-cd,  on  the  coiiditiou 
of  the  patii'tit,  the  size  and  iimhility  of  the  stoinacli,  and  whether  or  not  a 
permanent  canal  i>^  re<iuirt'(l.  'I'he  condition  of  the  patient  j)ermittin,<(,  and 
ji  pei-manent  ojx'ninrr  bein^^  re(iuired,  the  Ssabanejew-Fi-anck  motliod  as 
niodifn'il    hv    Kocliei-    is   all    that   can    he   desii-cd.      If  it  he   fouml   that   the 


Fig.  961. — ^Marwedel's  method  of  gastros- 
tomy. Incision  made,  tube  inserted 
and  stitched  in  jjlace. 


Fici.  963. — Marwedel's  metiiod  of  gastros- 
tomy. Tube  covered  by  suturing  to- 
gether muscular  and  serous  coats. 


stomach  is  small  or  adherent,  an  exchange  for  the  plan  of  Kader  or  Witzel 
may  be  made  with  satisfactory  results.  If  a  temporary  opening  be  in  view 
and  the  conditions  of  the  patient  are  favorable,  the  method  of  8enn,  of  Mar- 
wedel,  and  even  the  older  phxn  first  described,  can  be  practiced.  If  the  con- 
dition of  the  patient  is  precarious,  as  is  too  often  the  case,  the  older  method 
only  may  be  advisable.  It  seems  proper  to  say  in  this  connection  that  one 
should  select  that  method  of  practice  with  which  he  is  most  familiar,  pro- 
vided, of  course,  other  things  are  equal.  The  employment  of  cocain  anaes- 
thesia is  commended  in  those  instances  of  exhaustion  requiring  haste  and 
simple  technique  and  those  nnsuited  for  general  ana?sthesia. 

Gastro-enterostomy. — Gastro-euterostomy  signifies  the  establishment  of 
a  permanent  fistula  between  the  stomach  and  some  part  of  the  small  intes- 
tine to  secure  proper  emptying  and  rest  of  the  stomach.  Therefore,  the 
nomenclature  of  the  operation  can  be  extended  to  conform  to  the  special 
part  of  the  small  intestine  concerned  in  the  procedure,  as  gastro-duodenos- 
tomy,  gastro-jejunostomy,  gastro-ileostom}',  etc. 

The  Anatomical  Points. — The  relations  of  the  greater  and  lesser  abdomi- 
nal sacs  to  the  stomach,  transverse  colon  and  its  mesocolon,  the  jejunum,  and 
the  duodenum,  and  the  arrangement  of  the  great  omentum,  should  be  con- 
sidered carefully  before  beginning  the  operation  (Fig.  9-40).  Only  a  brief 
mention  of  the  most  striking  points  can  be  given  here  for  obvious  reasons. 
The  anterior  wall  of  the  stomach  is  in  the  greater,  the  posterior  in  the 
lesser  sac.  The  inferior  wall  of  the  transverse  colon  is  in  the  former,  the 
superior  wall  in  the  latter  sac,  and  the  transverse  mesocolon  separates 
the  two  horizontally.  The  mesentery  extends  downward  from  beneath  the 
transverse  mesocolon  near  its  attachment — ligament  of  Trietz  (Fig.  964) — at 
which  point  the  beginning  of  the  jejunum  is  located.     The  great  omentum 


Fig.  963. — Diagram  of  incisions  of  important  operations  (schematic). 

Lambeau's  flap  in  thoracoplasty  (page  1029).  h.  Delorme's  flap  in  thoracoplasty  (page 
1030).  c.  L)eiorme-]Mignon's  incision  in  approach  to  heart  ([lage  lOoG) :  blue  clotted 
lines  indicate  outlines  of  liver;  red  dotted  lines  indicate  outlines  of  stomach,  d.  In- 
cision in  gastrotomy  (page  739).  e.  Howse's  incision  in  gastrostomy  (page  743).  /. 
Jacobson's  incision  in  gastrostomy  (page  743).  Dotted  line  above  +  e  corresponds  to 
Witzel's  incision  in  gastrostomy  (page  746).  g.  Fenger"s  incision,  utilized  in  Halm's 
modification  (page  749).  h.  Dotted  line  +  d  corresponds  to  incision  in  posterior  gastro- 
enterostomy, i,  i.  Langenbiich's  incision  at  right  and  left  sides  for  abdominal  explo- 
ration of  kidneys  (page  838).  j.  Courvoisier's  incision  in  operation  on  gall  bladder  and 
ducts  (page  803  et  seq.).  k.  Vertical  incision  througli  outer  fibers  of  rectus  in  opera- 
tions on  gall  bladder.  /.  Meyer's  hockey-stick  incision,  and  the  imaginary  line  noted 
in  removal  of  appendix  (page  725  ef  seq.).  m.  Incision  in  iliac  colostomy  (i)age  675). 
n.  Incision  in  median  line  in  cceliotomy  below  navel  (page  608  et  seq.).  o.  Vertical 
and  transverse  oval  (Trendelenburg)  incisions  in  epicystotomy  (page  112C).  p.  Incision 
in  Bassini's  operation  for  radical  cure  of  hernia  (page  915  et  seq.).  q.  Langenbeck's 
incision  in  subpubic  entrance  to  bladder  (page  1122).  r.  Gall  bladder. 
754 


Ol'KUAl'lOXS  OX    VISCKRA   COXNECTEl)    Willi    I'KUrroN.KUM.     755 

luin<]i;s  from  the  givater  curviiture  of  the  storuiutli  and  tho  lower  surface  of 
the  transverse  colon,  coverinc:  over  the  latter,  'llw  omentum  may  be  hollow, 
the  cavity  communicating  witii  tlie  lesser  sac  al)ove  tiie  colon;  more  often 
its  layers  are  adhcriMit  to  eacli  other.  It  varies  in  density:  is  sometimes 
thick,  again  extrenu'ly  tliiii,  even  diaphanous.  It  may  be  smooth,  rough- 
ened, often  crumpled,  and  either  free  or  adherent  10  the  intestines  beneath. 
It  can  be  carried  upward  over  the  colon  aiul  stomach  or  to  one  side,  more 
easily  to  the  left.  These  simple  facts  exercise  an  important  bearing  on  tiie 
manipulation  of  the  structures.  The  jejunum  must  not  be  confounded  with 
the  ileum.     The  former  is  of  a  brighter  color,  denser  and  smoother  in  struc- 


FiG.  964. — The  operation  of  gastro-eiiterostomy.      a.  Ligament  of   Trietz.      b.  Opening 

into  jejunum. 


ture,  and  of  a  greater  capacity  than  the  latter ;  its  walls  also  are  thicker,  and 
the  root  of  its  mesentery  is  higher.  The  jejunum  is  readily  seized  bypassing 
the  thumb  and  finger  along  the  under  border  of  the  transverse  mesocolon  to 
its  root  and  grasping  the  first  intestinal  loop  that  is  felt  immediately  below. 
If  this  intestine  be  pulled  toward  the  wound  in  a  limited  degree,  the  move- 
ment is  arrested  by  the  intestine's  connection  with  the  immovable  part  of  the 
duodenum.  If  pulled  so  as  to  make  traction  on  the  opposite  extremity  of  the 
loop,  arrest  does  not  happen  because  of  its  continuity  with  the  remainder  of 
54 


756 


OPERATIVE  SURGERY. 


the  movable  small  intestine.  Although  not  anatomical,  it  is  needful  to  note 
that  the  flow  of  digestive  matter  in  the  stomach  is  principally  along  the 
greater  curvature,  from  the  cardiac  toward  the  pyloric  extremity,  and  that 
the  reverse  is  the  course  at  the  lesser  curvature  of  the  stomach.     In  the 


B  C 

Fig.  965. — The  operation  of  gastro-enterostomv.     Scheme  of  relations  in  the  attachments 
of  the  jejunum  to  the  stomach. 

s.  Stomach,     c.  Transverse  colon.    J.  Jejunum. 

z.  Gastro-colic  omentum.     *.  Great  omentum,     y.  Transverse  mesocolon. 

X.  Mesentery. 

A.  1.  Course  of  jejunum  to  anterior  surface  of  stomach, 
f.  Course  of  jejunum  to  posterior  surface  of  stomach. 

B.  Relations  of  parts  in  anterior  gastro-enterostomy. 

C.  Relations  of  parts  in  posterior  gastm-enterostomy. 

cardiac  two  tliirds  of  the  organ  the  food  is  propelled  in  a  nniform  gentle 
manner  in  the  directions  above  stated.  At  the  pyloric  third  it  is  more  pul- 
taceous,  and  is  expelled  into  the  small  intestine  in  an  intermittent  and  some- 
what forcible  manner.  In  the  intestine  the  course  is  downward  along  the 
canal.  These  facts  are  of  importance  in  the  technique  of  union  of  the  in- 
testine with  the  stomach  in  the  absence  of  special  provision  to  neutralize  the 
influence  of  the  contact  of  opposing  currents  at  the  seat  of  anastomosis. 
Two  varieties  of  procedure  have  heen  devised,  knoivn  respectively  as  anterior 
and  posterior  gastro-enterostomy .  In  the  former,  the  small  intestine  is 
passed  in  front  of  the  transverse  colon  and  joined  to  the  anterior  surface 
of  the  stomach  (Fig.  9Go,  B) ;  in  the  latter  the  intestine  is  carried  either 
through  the  transverse  mesocolon  or  ofastro-colic  omentum  and  united  to  the 
posterior  surface  of  the  stomach  (Fig.  965,  C).     An  objection  to  the  former 

method  (Fig.  9GG),  though  easier  of  attain- 
ment, is  the  stronger  tendency  to  regur- 
gitation of  the  intestinal  contents  into  the 
stomach ;  to  the  latter,  the  greater  difli- 
culty  of  joining  the  parts,  and  the  greater 
danger  of  peritoneal  infection  and  of  kink- 
ing of  the  intestine  on  account  of  the  in- 
fluence of  the  tissues  through  which  it 
passes.  The  regurgitation  into  the  stom- 
ach of  intestinal  contents  happens  from 
the  proximal  end  of  the  intestine  in  one 
of  two  ways :  1,  The  opposing  currents 
fill  the  intestine  directly,  which  finally  expels  its  contents  into  the  stomach  ; 
2,  the  fluids  may  gain  the  intestine  by  way  of   the   pylorus,  and  whether 


Fig.  966. — Gastro-enterostomy 
(diagrammatic). 


OI'KKATIONS   ON    VISCERA   CONNECTKD    WITH    rERlTUN.EUM.     757 


added  to  or  not  by  direct  reception  from  the  stomach,  they  are  expelled 
into  the  stoniacii  the  same  as  before. 

Tiie  prevention  of  tht-  cntraiicc  into  the  stomach  of  tiie  intestinal  con- 
tents and  entrance  of  the 
products  of  tiie  former  to 
tlie  intestine  are  promoted 
by  the  foUowing  ])lans  of  ac- 
tion :  1,  Hy  union  of  a  lialf- 
twistoil  hiop  of  intestine  with 
the  stomach  (Fig.  9(!T),  thus 
causing  a  similarity  in  the 
direction  (left  to  right)  of 
the  flow  of  the  contents  of 
tiie  united  organs  (IJockwitz). 
Unfortunately,  however,  the 
antici})ated  benefit  was  not 
fully  realized,  because  the 
curve  fashioned  by  the  opera- 
tion disappeared  with  return 
to  the  abdomen  of  tlie  parts, 
and  was  soon  followed  by  the 
development  of  a  s})ur  at  the  seat  of  union  which  caused  a  short-circuiting 
of  the  fluids  through  the  stomach  and  proximal  limb  of  the  bowel ;   also. 


"■■Hi.  967. — The  operation  of  anterior  gastro-enteros- 
tomy.     Union  of  a  half-twisted  loop  with  stomach. 


Fig.  968. — The  operation  of  anterior  gastro-enterostomy.     Entero-anastoinosis,  Braun's 

method. 


great  distention  of  the  duodenum  happened  not  infrequently,  and,  further- 
more, the  constriction   incident  to  the  pressure  of  the  loop  overlying  the 


Y58 


OPERATIVE   SURGERY. 


colon  (Fig.  965,  B)  was  regarded  with  disfavor.  2,  By  multiple  anastomosis 
(entero-anastomosis)  (Brauu) ;  3,  by  valve  formation  and  compression  adjust- 
ment of  the  parts  (Kocher) ;  4,  by  posterior 
gastro-enterostomy  (Von  Hacker). 

Entero-anastomosis  ( Braun). — Entero-anas- 
tomosis  is   practiced   in   gastro-euterostomy   to 


Fig.  970. — The  operation  of  anterior  gastro-enteros- 
tomv.     Entero-anastomosis,  Jaboulav's  method. 


cause  the  discharge  of  the  contents  of  the  proxi- 
mal part  of  the  intestine  into  the  general  intes- 
tinal current  so  far  below  the  point  of  junc- 
tion of  the  stomach  with  the  intestine  as  to 
divert  its  course  from  the  latter  situation 
(Fig.  908).  When  connected  in  the  manner  indicated  in  the  cut,  the  con- 
tents of  the  duodenum  are  short-circuited  through  two  channels — viz.,  into 

the  jejunum  below  the  point  of  union  with 
the  stomach,  and  also  into  the  contiguous  loop 
of  intestine  at  the  left  side  of  the  same  point. 
At   the   same  time   tlie   union  of    the  loops  of 


Fig.  969.— The  operation  of 
anterior  gastro-enterostomy. 
Entero-anastomosis  at  point 
of  intestinal  crossing,  Low- 
enstein's  method. 


Fig.  971.— The  operation  of 
gastro-enterostomy.  En- 
tero-anastomosis, Wolfler"s 
later  method. 


Fig.  972. — The  operation  of  anterior  ga.stro-enterostomy. 
Narrowing  of  proximal  of  bowel  hy  means  of  trans- 
verse sutures.  Von  Hacker's  method. 

viscera  harmonizes  the  direction  of  the  flow. 
Lowenstein  (Fig.  969)  and  Jaboulay  (Fig.  970) 
made  a  second  anastomosis  (entero-anastomosis) 
lower  down,  followed  by  Wolfler  with  his  later 
])lan  (Fig.  9T1).  The  functional  advantage 
gained  by  the  use  of  either  of  these  methods  is 


OPERATIONS   0\    VISCKIf.V    ("( (XNKCTKD    WITH    I'KIUTONMir.M.     759 

too  often  an  iimdequatc  ivcotiipciiso  for  tlin  cU'pri'.s.siii*^  t'tTect  011  the  ])atieiit 
of  the  lonjjjiT  time  eiiiithtyecl  aiul  tlie  greater  thinner  incurred  from  infcctioTi 


Fig.  973. — The  operation  of  anterior  gastro-  Fir,.  974. — The  operation  of  anterior  gastro- 
enterostomy. Narrowing  of  the  pylorus  enterostomy.  Narrowing  of  the  pylorus 
and  (UuHleuuin.  Doyen's  method.  Ldu-  and  duodenum,  I )oyen's  method.  Trans- 
gitudinal  section.  verse  section. 


by  the  adoption.  Not  a  few  attempts  directed  to  the  gut  have  been  pro- 
posed to  prevent  the  retiux  of  tlie  stomach  contents  into  the  proximal  part 
of  the  bowel.     The   methods   of  Von   Hacker 

(Fig.  972),  Doyen  (Figs.  973,  974),  Chaput  s^^^.^^^^^^;:^.^^^^-^^-^ 
(Fig.  975),  and  Kocher  are  each  commend-  p?^;; JS^^sp=;=Fr^i^  -  Hlg 
able  for  their  ingenuity,  but  Kocher's  only  con-       -f;-^;;-;  ^  ':  ^ 

tributes   sufficiently   to   commend  employment      ^£  V^^  '   t:^ 

when  posterior  gastro-enterostomy  can  be  prac-      ^ii 
ticed.  ^^ 

Kocher's  Method — After  thorough  cleansing      _^_^__^  _^^-^^^^^^^^__,^_  ^. 

of  the   stomach    by    means    of   a   boric-acid  or      ~      ~     ~  '.        ', 

,  -i^  1  1         ,      •  1  •  «        Fig.  975.— The  operation  of 

other  suitable  solution,  and  aseptic  treatment  01  anterior  o-astro-enterosto- 

the  operation    field,  make   an    incision    in    the  my-    Valve  between  stom- 

,.        ,.        J.  .        .      .      ,        .      ,         ,1    J  aeh  and  intestine.  Cliaput's 

median  hue  four  to  six  inches  in  length  down  method. 

to  the  peritonaeum  ;  arrest  haemorrhage  ;  divide 

the  peritonaeum  the  full  length  of  the  incision  ;  introduce  through  the  entire 
thickness  of  each  border  of  the  wound  one  or  more  strong  traction  sutures; 
push  the  omentum  upward  or  to  the  left ;  pass  the  fingers  beneath  the  trans- 
verse colon  along  the  under  surface  of  the  transverse  mesocolon,  and  seize  the 
nearest  loop  of  intestine  as  already  described.  Draw  the  loop  into  the  wound 
and  determine  its  identity  after  the  method  adopted  for  recognition  of  the 
jejunum  (page  755) ;  place  the  end  of  the  loop,  which  is  formed  at  a  point 
about  sixteen  inches  from  the  beginning  of  the  jejunum,  against  the  anterior 
surface  of  the  stomach  near  the  middle,  so  that  "  the  proximal  portion  of  the 
loop  ascends  and  the  distal  portion  descends  "  (Fig.  976) ;  suture  the  proxi- 
mal part  of  the  loop  to  the  stomach,  allowing  the  distal  part  to  lie  freely  upon 
the  proximal ;  form  a  valve  in  the  distal  part  of  the  intestine  near  the  stomach 
by  making  a  curved  incision  through  it  for  about  half  of  its  circumference, 
the  flap  thus  made  having  a  transverse  base  with  convexity  upward  ;  unite 
the  outer  surface  of  the  base  of  the  valve  with  the  lower  edge  of  the  wound 
in  the  stomach,  the  convex  border  remaining  free.  Join  the  upper  border 
of  the  opening  in  the  stomach  with  the  concave  border  of  the  opening  in 
the  intestine  resulting  from  the  valve  formation.     Interrupted  or  continuous 


reo 


OPERATIVE   SURGERY. 


silk  sutures  are  employed  for  these  purposes;  usually  the  former  and  some- 
times both  together.  The  mechanism  of  valve  formation  and  compression 
adjustment  is  explained  by  Kocher  as  follows  :  "  The  valve  forces  the  escape 
of  the  stomach  contents  into  the  distal  part  of  the  intestine  and  prevents 
the  entrance  into  the  stomach  of  the  contents  of  the  proximal  segment  of 

intestine  by  directing 
them  along  into  the  dis- 
tal portion.  The  com- 
pression of  the  distal 
part  while  in  active  use 
closes  the  underlying 
proximal  end  at  the  seat 
of  union,  which  is  in 
turn  readily  opened  by 
tiie  escaping  contents 
of  the  proximal  part 
when  the  distal  is  not 
in  action."  During  the 
entire  procedure  immu- 
nity from  infection  inci- 
dent to  the  making  of 
the  openings  into  the 
stomach  and  intestine, 
and  from  other  steps  of 
the  procedure,  is  guard- 
ed against  by  gauze  pack- 
ing properly  arranged 
around  the  abdominal 
opening,  and  by  the  exclusion  of  visceral  contents  from  the  sites  of  the  in- 
cisions by  digital  manipulation  and  pressure.  After  thorough  cleansing  of 
the  parts  with  the  Avarm  saline  solution  they  are  cautiously  inspected  for 
the  presence  of  faulty  sewing  before  being  returned  to  the  peritoneal  cavity. 
The  abdominal  wound  is  then  closed  and  dressed  in  the  usual  manner,  and 
the  patient  is  returned  to  bed. 

Braun  recommends  a  more  precise  method  of  union  by  joining  with 
each  other  the  borders  of  the  respective  tissues  of  the  viscera  as  soon  as  they 
are  divided.  First  unite  the  intestinal  loop  with  the  stomach  by  a  long 
posterior  continuous  suture  carried  through  the  serous  surfaces  only,  both 
ends  being  left  long.  Make  an  incision  at  the  proper  place  through  the 
serous  and  muscular  tunics  only  of  the  organs,  and  unite  the  severed  borders 
posteriorly  with  each  other  by  an  independent  suture ;  press  aside  the  con- 
tents of  the  stomach  and  intestine  with  the  fingers,  holding  the  parts 
securely  in  position  ;  open  into  the  intestine  and  stomach  by  division  of 
their  mucous  membranes,  and  unite  the  borders  of  the  mucous  membranes 
with  each  other  by  a  continuous  anterior  mucous-membrane  suture;  intro- 
duce a  second  anterior  suture,  which  passes  through  the  entire  thickness  of 
the  walls  of  the  respective  viscera;  and,  lastly,  introduce  a  final  anterior 


Fig. 


976. — The  operation  of  gastro-enterostomy.  Kocher's 
method,  a.  Valve  formed  from  jejunum,  h.  Location 
of  sutures  of  posterior  segment,  c.  Location  of  sutures 
of  anterior  segment,  d.  Posterior  continuous  suture. 
e.  End  of  posterior  suture  left  for  use  as  anterior  suture. 


uriOUATlONS   ON    VISCERA   CONNKCTKI)    Wl'III    I'KUlTUN.ia  M. 


roi 


Fig.   977. — 'I'lu'  o|K'ration  of  gastro-enterostoiny,  Son- 
iienberg's  inetliod.     Sutures  in  place. 


mnsculo-scrous  suture,  which  is  formed  by  utilization  of  the  ends  of  the  long 

posterior  serous  suture  before  described. 
Sonnenberg's  Method.— 

Puss  through  and  fasten  to 

the  borders  of  the  incision 

into    the   stonuich    at  sliort 

intervals  numerous  long  silk 

sutures;    uuike  an    incision 

into    the    long    a.xis   of   the 

small  intestine,  and  sew  its 

borders    with   an    overhand 

continuous  suture  of  catgut 

(Fig.  977)  ;    make   another 

opening  into   the  small  in- 
testine, an  inch  or  so  below 

the  former;    introduce    the 

ends  of  the  gastric  sutures 

into  the  j^rimary  intestinal 

opening,    carry    them    out 

througli  the  secondary  intes- 
tinal   one,    and    by    gentle 

traction  on  them  bring  the 

borders  of  the   gastric  and 

intestinal  openings  in  contact  with  each  other  (Fig.  978) ;  they  are  united 

together  in  this  position  by  silk  sutures  applied  in  the  usual  manner.     It 

should  be  noted  that  the  method  recalls  Maunsell's  (Fig.  809)  in  one  essen- 
tial particular — the  long 
sutures.  The  ingenuity  of 
these  methods  surpasses 
considerably  their  present 
practical  utility  when  com- 
pared with  more  modern 
plans  of  procedure. 

Posterior  Gastro-enter- 
ostomy  (Von  llacker). — 
After  the  usual  gastric 
preparation  and  other 
preparatory  steps,  make  an 
incision  in  the  median 
line  from  a  point  two 
inches  below  the  xiphoid 
cartilage  to  a  point  below 
the  umbilicus  (Fig.  963), 
increasing  thereafter  the 
length  in  either  direction 
as  may  be  required  ;  raise 
and  push  upward  over  the 


-Vv 


Fig.  978. — The  operation  of  gastro-enterostomy,  Sonnen- 
berg's method.     Sutures  ready  for  approximation. 


7r.2 


OPERATIVE  SURGERY. 


(3 


stoniJich  the  omentum  and  the  ti'aiisverse  colon  (Figs.  970  and  905,  C),  and 
liohl  them  in  pLice  witli  steriHzed  gauze  compresses  ;  recognize  and  isokite  the 
beginning  of  the  jejununi;  cause  an  assistant  to  so  grasp  the  stomach  with 
both  hands  that  the  fingers  will  be  applied  to  the  posterior  and  the  thumbs 

to  the  anterior  surface  of 
the  organ  ;  pronate  tlie 
forearms,  thus  pressing  the 
posterior  wall  downward 
and  upward  against  the 
transverse  mesocolon ;  slit 
the  mesocolon  parallel 
with  its  vessels  at  the 
point  of  proposed  entrance 
to  the  stomach  with  for- 
ceps ;  cause  the  stomach  to 
protrude  through  the  slit 
by  pressure  of  the  thumbs, 
and  promptly  stitch  the 
separated  borders  of  the 
slit  to  the  posterior  wall  of 
the  stomach  (Fig.  980); 
push  aside  the  contents  of 
the  first  loop  of  the  Jeju- 
num for  the  distance  of  six 
or  eight  inches,  with  the 
thumbs  and  fingers,  and  apply  proper  clamps  to  prevent  their  return ;  apply, 
with  or  without  looping  (Figs.  979,  980),  the  empty  segment  of  gut  to  the 
posterior  wall  of  the  stomach,  and  unite  these  with  each  other  at  the  lower 
border  by  means  of  sutures  passed  through  the  sero-muscular  coats  only; 
open  the  stomach  obliquely  downward  from  left  to  right  for  two  inches ; 
open  the  intestine  in  the  long  axis  of  the  free  border  a  similar  distance,  and 
unite  the  borders  of  the  respective  openings  with  each  other  in  the  usual 
manner  by  sewing ;  remove  the  proximal  intestinal  clamp,  and  narrow  this 
part  of  the  intestine  near  the  anastomosis  by  infolding  the  walls  longitudi- 
nally in  several  places,  and  confining  them  in  this  position  by  sutures  passed 
through  the  sero-muscular  coats  of  the  projecting  borders,  thereby  forming 
a  rosette  outline  of  the  lumen  of  the  gut  at  this  situation  (Fig.  972). 
Entero-anastomosis  may  be  practiced  instead  (page  758).  The  parts  are 
then  cleaned  thoroughly,  the  protective  packing  is  removed,  the  viscera  are 
returned  into  place,  and  the  abdominal  wound  is  closed  by  tier  suturing. 

The  Remarks. —  Vo7i  Ilacher  claimed  that  the  facility  of  procedure  and 
freedom  from  the  danger  of  peritoneal  infection  when  the  parts  are  thus 
manipulated  are  equal  to  those  in  the  method  of  union  at  the  anterior  sur- 
face of  the  stomach,  and  that  the  liability  to  intestinal  kinking  and  regurgi- 
tation of  intestinal  contents  into  the  stomach  is  reduced  to  a  minimum  for 
all  operations,  which  subsequent  experience  has  confirmed.  The  contentions 
of  many  others  that  the  manipulations  of  the  stomacli  in  this  method  being 


Fig.  979. — The  operation  of  posterior  gastro-enterostomy. 
Jejunum  looped  to  secure  uniformity  of  peristalsis, 
Von  Hacker's  method. 


(H'liKA  rioxs  ox  vis("i':i{.\  coxxKcriiit  with   imiimtoxju'm. 


^(\:^ 


liiirsh  :it  the  bi'st,  ami  Llii'  opportunity  l'<»r  |)rti|ti'r  union  of  the  viscera  and 
prevention  of  peritoneal  infection  heini,^  ui'eatly  hindered,  thereby  neutraliz- 
ing the  additional  advantages  gained  in  favor  of  this  metlutd  of  [iraetice, 
have  not  proved  true.  Certainly,  the  uniformity  in  the  direction  of  tlu;  How 
of  the  contents  of  the  viscera,  and  their  more  natural  position,  together 
with  the  influence  of  the  force  of  gravity  on  the  contents  of  the  stomach, 
emphasize  the  wisdom  of  this  method.  Practically  the  influence  of  gravity 
seems  sufhcient  to  meet  the  requirements,  as  direct  anastomosis  (Fig.  9S0) 
is  now  quite  commotdy  employed  with  satisfactory  results.  Transverse  division 
of  the  mesocolon  should  be  avoided,  because  of  the  great  liability  of  injury 
to  the  vascular  suj)- 
ply  of  the  colon  and 
the  danger  of  subse- 
quent gangrene.  Cau- 
tious and  effective  su- 
turing of  the  stomach 
to  the  separated  bor- 
ders of  the  opening  in 
the  mesocolon  pre- 
vents nndue  traction 
on  the  intestine  and 
the  occurrence  of  a 
slit  through  which  the 
intestine  may  escape 
with  dangerous  re- 
sults. The  employ- 
ment of  a  medium- 
sized  Murphy  button 
(page  765)  to  unite  the 
intestine  with  the 
stomach,  and  a  small 
one  for  entero-anasto- 
mosis,  has  shortened  Fiu.  9S0.— 'I'iie  diieiation  of  [Kistcrior  gast ro  -  enterostomy, 
the  time  of  the  opera-  Transverse    colon   and   omentum    turned    up,  transverse 

,         .'  mesocolon  slit  sutured  to  stonuieh,  and  intestine  directly 

tion  so   much  that  its  united  to  stt>mach,  Von  Hacker's  method, 

scope  has  been  consid- 
erably extended  and  the  results  much  improved.     The  making  of  an  open- 
ing through  the  gastro-colic  omentum  is  not  a  matter  of   trilling  signifi- 
cance. 

Roux's  Method. — Rovx,  after  turning  up  over  the  stomach  the  great 
omentum  and  the  transverse  colon,  made  an  opening  through  the  posterior 
border  of  the  transverse  mesocolon  a  little  to  the  left  of  the  median  line  of 
the  vertebral  column,  thus  exposing  the  stomach  near  the  pyloric  end.  The 
jejunum  was  then  divided  several  inches  from  the  plica  duodeno-jejunalis 
(Fig.  981),  the  distal  end  of  the  bowel  implanted  by  sewing  into  the  pos- 
terior surface  of  the  stomach  (r),  and  the  proximal  end  (a)  united  in  the 
same  manner  with  the  distal  at  a  point  below  the  connection  of  the  latter 


"(U 


OPERATIVE   SURGERY, 


with  the  vstomach  (b)  (Fig.  981).     The  employment  of  the  ^Murphy  button 
in  this  instance  would  no  doubt  greatly  facilitate  the  operation. 

T/ie  Precautions. — As  complete  isolation  as  is  possible  of  the  operation 
field  by  aseptic  packing  and  use  of  rubber  dam  should  be  practiced  in  gastro- 


Tifflirwrntiinrn-., 


Fig.  981. — The  operation  of  posterior  gastro-enterostoiny,  Roux's  method,  a.  Proximal 
end  of  jejunum,  h.  Union  of  proximal  and  distal  ends  of  jejunum,  c.  Distal  end 
of  jejunum  joined  to  pyloric  portion  of  stomach. 

enterostomy  to  prevent  peritoneal  infection.  The  occurrence  of  this  mis- 
fortune calls  for  patient  and  thorough  cleansing,  and  perhaps  for  the  establish- 
ment of  effective  drainage.  The  line  of  each  form  of  union  should  be  carefully 
inspected,  and  points  of  doubtful  coaptation  should  be  fortified  by  additional 
stitches  before  the  return  of  the  viscera,  as  post-operative  leakage  will  be 
promptly  fatal.  The  exclusion  of  the  contents  of  the  organs  from  the  seat  of 
proposed  union  must  be  rigorously  practiced  by  every  practical  method  (page 
659),  for  obvious  reasons.  The  development  of  a  post-operative  peritonitis 
indicating  infection  calls  for  prompt  exposure  of  the  parts,  to  repair  defects 
and  remove  deleterious  agents.  The  tendency  to  kinking  of  the  gut  by  oper- 
ative confinement  or  constriction  from  superimposed  weight  or  pressure 
should  be  anticipated  and  remedied  in  the  first  instance  by  supporting  sutures 
applied  at  either  side  of  the  anastomosis  (Kappeler)  before  the  abdomen  is 
closed.  A  sharp  bend  in  the  jejunum  beyond  the  point  of  union  with  the 
stomach,  its  constriction  at  the  seat  of  the  slit  in  the  mesocolon,  and  closure 


oi'KKATioNs  OX  viscKiiA  coNNKi ' ri;i)  WITH   i'i;i:i'r(j.\ j<:uM.    705 


of  the  tniiisvorse  colon  by  tlio  prossuro  of  tlic  loop  of  iiitcstiiio  carried  in 
front  of  it  for  attachment  to  the  stomach,  are  practical  illnstratious  of  these 
dangers,  (iastric  alinientatioi\  of  small  atnoiiiit,  and  of  a  fluid  and  bland 
nature  only,  should  be  given  for  the  lirst  few  hours,  if  circumstances  will 
])ermit,  rectal  alimentation  of  a  more  substantial  character  being  employed 
at  the  same  time.  That  the  ojiening  of  intercommunication  should  be  suf- 
ficiently large  to  obviate  complete  closure  is  clearly  apparent.  An  opening 
two  inches  in  length  in  incision  cases  is  regarded  as  ample  to  prevent  this 
sequel.  An  im{)airment  of  the  vascular  supply  of  the  viscera  should  be 
avoided  by  careful  treatment  of  the  mesentery  to  obviate  the  danger  of  gan- 
grene of  the  intestines.  Only  the  upper  part  of  the  jejunum  should  be 
utilized,  remembering  that  the  danger  of  death  from  inanition  increases  in 
proportion  to  the  exclusion  of  the  small  intestine  from 
the  field  of  nutrition.  The  anastomosis  should  l)e 
made  at  a  point  as  far  as  possible  from  the  seat  of  the 
disease  and  as  near  the  greater  curvature  as  practica 
ble,  where  the  organ  is  thin  and  atroi)hied.  The  an- 
astomotic point  of  the  jejunum  is  from  twelve  to  fif- 
teen inches  from  its  duodenal  junction.  Measures 
should  be  taken  in  every  instance,  when  possible,  to 
prevent  the  pancreatic  and  biliary  fluids,  as  well  as 
those  of  the  stomach  itself,  from  returning  to  the 
stomach  by  regurgitation  and  short-circuiting,  for 
reasons  both  obvious  and  well  understood.  In  other 
words,  means  must  be  taken  to  permit  of  prompt 
and  complete  emptying  of  the  proximal  portion  of 
the  small  intestine.  The  intermittent,  expulsive 
character  of  the  movements  of  the  pyloric  end  of  the 
stomach  during  digestion  (page  750)  suggests  the  wis- 
dom of  making  the  anastomosis  at  this  situation  when 
])racticable.  The  employment  of  valvular  flap  de- 
vices for  the  purpose  is  less  reliable,  more  difficult  and 
complicated  than  that  of  the  Murphy  button,  the 
bone  bobbin,  and  other  similar  agents. 

Entero-((naf<tomofiis  with  the  Murphy  button  can 
be  quickly  carried  into  effect — after  opening  the  in- 
testine for  union  with  the  stomach — by  introducing 
through  the  opening,  by  means  of  ordinary  forceps 
((Jallet)  (Fig.  982),  or  forceps  devised  for  the  pur- 
pose (Turnure),  a  segment  of  button  into  each  limb 
of  the  intestine  in  such  a  manner  that,  when  closed 
by  opposing  pressure,  the  stems  of  the  segments 
penetrate  the  intervejiing  tissues  and  complete  the 
anastomosis  when  locked. 

The  Results. — MuiyJiy  reports  with  the  use  of  his  button,  entero-en- 
terostomies,  550  cases;  543  reported  results,  with  415  recoveries,  or  70.58 
per  cent ;  deaths,  23.42  per  cent  (written  communication). 


Fig.  983. — The  operation 
of  cntero- anastomosis, 
Gallet's  method,  with 
ordinary  forceps.  a. 
Weir's  modification  of 
stem  of  Murpliy's  but- 
ton. 


766  OPERATIVE   SURGERY. 

The  Eemarlcs. — The  careful  evacuation  of  the  stomach  and  intestines 
before  operation  is  a  wise  precaution,  and  a  time-saving  measure  during 
operation,  as  the  tendency  to  and  danger  of  infection  is  lessened  by  this 
means.  Preparatory  stimulation  and  strengthening  of  tlie  patient  is  advis- 
able when  the  already  de})ressed  state  demands  it  and  time  will  permit.  The 
continued  regurgitation  into  the  stomach  of  the  intestinal  contents  is  delete- 
rious in  an  extreme  degree,  and  should  be  combated  by  lavage,  medication, 
and  posture.  The  median  abdominal  incision  is  commonly  employed  in  this 
operation.  If  freer  exposure  of  the  parts  is  desired,  this  incision  may  be  sup- 
plemented by  a  transverse  one  three  or  four  inches  in  length  made  at  right 
angles  with  the  former.  Union  by  Halsted's  method  of  sewing  is  more  secure 
and  promptly  accomplished  than  by  the  ordinary  methods  (page  G-iG),  and 
the  importance  of  the  submucous  fibrous  tissue  in  this  connection  should  be 
kept  in  view  (Figs.  788  and  793).  The  Murphy  button  affords  the  quickest 
means  of  union,  but  is  open  to  the  comparative  objection  of  sometimes 
remaining  indefinitely  as  a  foreign  body  in  the  stomach  or  intestine.  It 
does  not  appear,  however,  that  the  retention  has  been  followed  by  a  troitble- 
some  sequel.  A  relative  increase  in  the  size  of  the  intestinal  end  of  the  but- 
ton seems  likely  to  favor  its  escape  into  the  intestine,  thus  lessening  the  fre- 
quency of  its  entrance  to  and  retention  in  the  stomach.  The  use  of  the 
Murphy  button  may  prevent  entirely,  and  certainly  will  for  some  time,  the 
formation  of  a  spur,  but  in  some  cases  marked  contraction  of  the  anasto- 
motic opening  takes  place.  Weir  bevels  the  end  of  the  stem  of  the  male 
part  of  the  button  (Fig.  98'-i,  f/,)  to  facilitate  perforation  of  the  intestinal  wall 
in  entero-anastomosis  by  Gallet's  method.  Carle  draws  the  borders  of  the 
intestinal  opening  around  the  stems  of  the  button  by  means  of  one  or  two 
Lembert  sutures,  instead  of  bv  the  purse-string  suture  commonly  emploved 
(Fig.  816). 

Jejunostoiny  may  be  practiced  when  gastro-enterostomy  is  not  possible  by 
the  method  of  Maydl  (Fig.  024)  or  Albert  (Fig.  1333).  In  each  the  abdominal 
incision  is  made  in  the  median  line  above  the  umbilicus ;  in  the  former  the 
loop  of  jejunum  is  severed  between  suitable  restraining  appliances  (Fig.  8G8), 
and  the  proximal  end  is  implanted  into  the  convex  surface  of  distal  part.  In  the 
latter  plan  entero-anastomosis  (jejuno-jejunostomy)  is  performed,  and  the  apex 
of  the  intestinal  loop  is  carried  out  through  the  median  incision,  thence  be- 
neath the  integument  through  a  secondary  opening  as  in  gastrostomy  (Fig.  952). 

The  Results. — Gastro-enterostomy.  In  Wolfler's  method  the  general  rate 
of  mortality  was  38.09  per  cent  in  231  cases  ;  in  Yon  Hacker's,  35.52  i)er  cent 
in  152  cases.  Carle  reports  GO  cases  of  his  own  in  which  the  Murphy  button 
was  employed  without  a  death.  His  combined  rate,  however,  was  7.4  per  cent 
(Keen).  Czerny  operated  in  a  series  of  35  cases  with  Murphy's  button  with 
a  mortality  of  34.28  per  cent,  and  later  in  a  second  series  of  G5  cases  with  a 
mortality  of  22.28  per  cent.  Murp]nfs  latest  report  of  the  use  of  his  button  : 
gastro-enterostomies,  575  cases;  417  reported  results,  with  31 T  recoveries,  or 
76.01  per  cent;  deaths,  24.03  per  cent  (written  communication). 

Decalcified  bone  plates,  61  cases  with  14  deaths  (Magill). 

The  present  rate  for  all  cases  is  about  30  per  cent  mortality ;  that  for 


OI'KKAIIONS   ON   VISCERA  CONNECTED    WITH    PKI{1T0N.1':UM.     JCJ 


Fig.  983. — lustrumeiits  employed  iu  operations  on  the  stomach. 
•a.  Scalpels,    b.  Bistouries,    c.  Poreipressure.    d.  Curved  and  straight  scissors 


forceps.     /.  Xeedle-holder.      /;.  Retractor,      i.  Sponge-holder, 

tare  carrier.     A*.  Aneurism  needle. 

dies.    71.  r.  Silkworm  and  catgut,    o. 

needles  threaded  with  black   silk, 

the  large  anchored  to  forcipressure, 

needed. 


e.  Thumb 
/.  Cleveland's  liga- 
/.  Blunt  hook.  m.  Curved  and  straight  nee- 
Traction  loops,  p.  Straight,  round,  and  curved 
q.  Small  and  large  gauze  pads,  with  tapes, 
Broad  retractors,  tenacula.  and  rubber  dam  are 


768 


OPERATIVE  SURGERY. 


malignant  disease,  .'54.5,  and  for  non-malignant,  14.3  per  cent.  Union  by  the 
JMurphy  button  appears  to  give  13  per  cent  better  rate  than  sewing.  The 
average  longevity  after  operation  in  malignant  disease  is  about  eight  months ; 
in  non-malignant,  sufficient  time  has  not  yet  elapsed  to  establish  a  record. 

Increased  experience  will  no  doubt  improve  the  record. 

Pylorectomy. — The  term  pylorectomy  is  applied  to  the  operation  for 
removal  of  the  pylorus  and  as  much  of  the  stomach  and  duodenum  as  mav 
be  involved  by  the  disease  calling  for  the  procedure.  Before  beginning  the 
operation,  the  attention  of  the  surgeon  should  be  directed  carefully  to  the 
vascular  supply  of  the  pylorus  and  its  relation  to  the  nutrition  of  contiguous 
structures,  as  modified  by  the  morbid  effects  of  the  disease  (Fig.  984).     The 


Fig.  984. — The  anterior  surface  of  the  stomach,  showing  its  relations  and  vascular  supply, 
rt.  Cystic  branch,     h.  Probe  passing  through  foramen  of  Winslow. 

probable  complications  incident  to  the  procedure  should  be  anticipated  as 
far  as  possible,  and  the  ])roper  resources  for  their  relief  contemplated,  in 
order  that  wise  forethought  may  contribute  to  prompt  and  discreet  action 
during  the  operation. 

Preparatory  treatment,  characterized  by  frequent  washing  out  of  the 
stomach,  regulation  of  the  bowels,  sterilized  diet,  and  proper  stimulation 


OPERATIONS   ON    VISCKKA    ('ONNK("TKI)    Willi    I'KKrioN.KL  M.     7(;<) 

slioiikl,  when  possible,  precodo  for  some  days  tlie  more  active  measures.  In 
all  instances  the  stomach  should  be  completely  emptied,  and  carefully  cleansed 
by  a  mild  antisejjtic  Uuid,  such  as  a  boric  or  salicylic-acid  solution,  an  hour  or 
80  before  o})enition.  Both  local  and  general  aseptic  measures  should  be  care- 
fully practiced  and  provided  for  in  advance  of  the  procedure.  Means  cal- 
culated to  prevent  and  overcome  shock  should  be  at  hand  ({lage  105)  for 
prompt  utilization, 

A  cai'eful  counting  of  the  sponges,  pads,  and  of  other  agents  employed  in 
this  and  all  abdominal  jn-ocedures  should  he  made  at  the  outset,  and  their 
introduction  into  the  cavity  definitely  noted  by  some  responsible perso7i  indi- 
cated for  the  purpose,  in  order  that  all  may  be  accounted  for  before  the 
abdominal  wound  is  closed. 

Tlie  Operation  of  Pylorectomy  (Koclier). — For  the  sake  of  a  more  lucid 
description,  the  operation  can  be  divided  into  three  stages  of  procedure : 
(1)  exposure  of  the  pylorus;  (::i)  isolation  of  the  pylorus;  (3)  resection  of 
the  diseased  tissues.     The  primary  incision  is  made  in  the  median  line. 

The  Exposure  of  the  Pylorus. — Press  upward  the  pylorus  to  the  proposed 
site  of  the  abdominal  incision,  if  need  be;  make  a  vertical  incision  down  to 
the  i)eriton£eum  in  the  median  line  above  the  navel,  of  sufficient  length  to 
permit  of  digital  examination  of  the  diseased  area;  arrest  haemorrhage,  open 
the  peritonteum,  introduce  the  thumb  and  index  linger,  and  carefully  esti- 
mate the  extent  of  the  disease  and  note  the  presence  of  glandular  and  other 
secondary  involvements.  If  further  procedure  be  advisable,  introduce  through 
the  opening  a  broad,  fiat  sponge  or  thick  gauze  pad  to  collect  the  blood,  and 
extend  the  incision  sufficiently  for  the  purpose  by  means  of  scissors;  arrest 
the  bleeding  points  and  make  a  second  incision  at  right  angles  to  the 
median,  if  necessary  for  the  proper  observation  and  manipulation  of  the 
parts. 

The  RemarTcs. — The  incision  in  the  median  line  in  the  making,  the  arrest 
of  haemorrhage,  and  in  subsequent  union  of  the  borders,  is  the  best,  as  any 
needless  increase  of  time  is  to  be  avoided.  However,  the  wound  should 
be  enlarged  transversely  to  the  right  or  left  when  expediency  demands 
a  more  extended  examination  or  manipulation  than  the  median  incision 
affords.  The  presence,  location,  and  the  extent  of  adhesions,  the  existence 
and  situation  of  enlarged  glands  and  involvement  of  the  liver,  gall  bladder, 
pancreas,  colon,  or  stomach,  should  be  carefully  determined.  Adhesions 
between  the  stomach,  the  colon  and  liver,  and  enlarged  glands  near  the  pan- 
creas, especially  the  head,  at  the  lesser  curvature  of  the  stomach  near  the 
cardia  and  oesophagus,  at  the  greater  curvature,  especially  at  the  pylorus  and 
between  the  stomach  and  colon  and  in  the  omenta,  are  not  infrequent  at  one 
or  more  situations  in  these  cases.  If  extensive  glandular  enlargement  or 
adhesions  are  present,  gastro-enterostomy  should  be  done  instead  of  pylo- 
rectomy. 

The  Isolation  of  the  Pylorus. — Raise  the  diseased  tissues  carefully  into 
the  wound  as  far  as  practicable,  and  note  again  the  extent  of  the  morbid 
process;  separate  the  greater  and  lesser  omenta  from  the  stomach  and  duo- 
denum bv  means  of  ligatures  and  scissors  carried  as  close  to  the  structures  as 


770 


OPERATIVE   SURGERY. 


is  consistent  with  proper  removal  of  the  disease  (Fig.  985) ;  lift  the  isolated 
tumor  still  farther  into  the  wound  and  pack  around  it  hot,  dry  aseptic  gauze 
or  sponges  so  completely  as  to  prevent  the  possibility  of  infection  of  the 
abdominal  cavity  and  exposed  peritonaeum  ;  clamp  the  duodenum  close  to 
the  edge  of  the  tumor  and  outside  of  this  point  (Fig.  986),  and  also  the  stom- 
ach at  the  cardiac  side  of  the  tumor,  with  one  or  more  forceps  or  by  other 
suitable  means,  after  pushing  aside  the  contents. 

The  Remarks. — The  diseased  portion  should  be  raised  well  out  of  the 
abdominal  cavity  in  order  to  permit  of  as  complete  extra-peritoneal  opera- 
tion as  possible.  The  severance  from  the  stomach  of  the  greater  and  lesser 
omenta  extends  a  little  beyond  the  diseased  area  (Fig.  986,  Z»,  /),  and  is 
accomplished  by  double  ligatures  of  chromicized  gut,  or  by  silk  applied  to 


Fig.  985.— The  posterior  surface  of  the  stomach,  a,  a.  Gastrocolic  omentum,  h.  Pan- 
creas beneath  transverse  mesocolon,  c.  Spleen,  d.  Splenic  vein.  e.  Descending 
duodenum.    /.  Papillary  tubercle. 

isolated  portions  of  the  omental  tissue  by  means  of  an  aneurism  needle  or 
Cleveland's  ligature  carrier  (Fig.  983,  /).  The  width  of  the  portion  grasped 
by  the  respective  ligatures  will  be  governed  by  the  thickness  of  the  tissue 
and  the  size  and  number  of  its  vessels,  remembering  to  include  only  the 
amount  that  can  be  securely  tied.  The  illustration  (Fig.  986)  indicates 
approximately  the  number  and  distance  between  the  ligatures. 

The  Resection  of  Diseased  Tissues  (Fig.  986). — Sever  the  duodenum  with 
scissors  and  thoroughly  disinfect  the  distal  end  with  a  strong  sublimate  solu- 


OPERATIONS   ON    VISCKIIA   CONNECTED    WITH    TERITONvEUM.     771 

tiou  ;  wrup  the  cud  in  sti'iilizi'd  giiuze  ;iiid  turn  it  outward  with  the  for- 
ceps {a) ;  wrap  tlie  proximal  iiid  in  moistened,  sterilized  gauze  and  raise  the 
tumor  upwartl  still  farther;  cause  the  assistant  to  grasp  the  stomach  at  each 
border  beyond  the  line  of  })r<)posed  section  with  tlie  tiiumb  and  index  linger 


Fig.  986. — The  operation  of  resection  of  the  pylorus,  first  stage,  Kochers  method,  a. 
Liver,  b.  Line  of  severance  of  lesser  omentum,  c.  Duodenum,  d.  Line  of  division 
of  duodenum,  e.  Diseased  mass.  /.  Line  of  severance  of  greater  omentum,  g. 
Line  of  division  of  the  stomach,  h.  Fingers  of  assistant  acting  as  compressing 
agents. 


of  each  hand,  or  with  the  index  and  middle  fingers  of  the  same  (Fig.  986,  //) ; 
surround  the  stomach  at  the  seat  of  proposed  section  and  the  hands  of  the 
assistant  holding  it  with  an  abundance  of  sterilized  gauze ;  with  scissors 
divide  the  stomach  parallel  with  the  clamp,  arresting  the  bleeding  points 
with  forcipressure  as  they  appear ;  remove  the  tumor,  wipe  away  all  infect- 
ing agents  that  may  have  escaped,  and  ligature  the  important  vessels.  The 
union  of  the  viscera  may  be  made  in  two  ways — i.  e.,  directly  as  immediately 
follows,  or  indirectly  (pylorectomy  with  gastro-enterostomy),  as  practiced 
by  Kocher  (Fig.  99-i),  and  properly  the  completion  of  the  operation  just 
described. 

77/e  EemarJcs. — The  division  of  the  walls  of  the  stomach  is  modified 
somewhat  by  the  outline  of  the  disease,  the  aim  being  to  follow  this  outline 
as  nearly  as  may  be  consistent  with  expedient  repair ;  a  healthy  margin  of 
not  less  than  half  an  inch  should  always  be  removed  at  either  extremity  of 
the  disease.  Both  walls  of  the  stomach  should  be  divided  along  similar 
lines,  unless  too  great  sacrifice  of  healthv  tissue  be  the  result  of  this  action. 


Y72 


OPERATIVE   SURGERY. 


Fig.  987. — The  operation  of  pylorectomy,  showing 
lines  of  division  at  either  limit  of  disease,  a. 
Transverse  division  of  duodenum,  b.  c.  Trans- 
verse and  oblique  divisions  of  the  stomach. 


The  lines  of  section  are  the  transverse  and  the  oblique  (Fig.  087),  the 
latter  being  single  or  double  (Fig.  988).     The  single  oblique  line  begins  at 

the  greater  curvature  and 
extends  upward  toward  the. 
cardiac  or  the  pyloric  end  of 
the  organ,  as  the  location  of 

l^      F     El  ^-      /-  ?^>-~ -<  the    disease     may     require. 

^k^/        \X  /^    ^  ^'^16  double  oblique  line  of 

division  is  applied  to  the 
upper  and  lower  portions  of 
the  main  incision,  so  as  to 
establish  an  extremity  that 
will  properly  fit  the  distal 
end  of  the  duodenum  (Fig. 
989). 

Tlie  Joining  of  the  Intes- 
tine and  Stomacli. — The  seat 
of  insertion  of  the  duodenum  being  determined,  the  remaining  part  of  the 
gastric  wound  is  promptly  closed  by  one  of  two  methods  of  sewing :  1.  By 
means  of  an  overhand  continuous  silk  suture,  carried  up 
to  the  point  of  duodenal  implantation,  followed  by  inversion 
of  this  line  of  sewing  by  continuous  or  interrupted  Lembert 
or  Halsted  suturing  carried  so  as  to  include  the  submucous 
fibrous  coat.  2.  By  union  of  the 
mucous  coats  with  a  continuous  su- 
ture, supplemented  by  a  double  row 
of  Lembert  sutures  carried  through 
the  sero-muscular  coats,  or  the  second 
row,  need  include  only  the  serous 
coats.  The  former  plan  is  employed 
by  Kocher,  only  continuous  sutures 
being    used    (Figs.     871    and    872). 

This  plan  is  certainly  the  most  expeditious,  and  is  equally  secure.     In  the 
instance  of  transverse  division  of  the  stomach  the  duodenum  is  implanted 

at  the  upper  or  lower  portion 
of  the  wound  as  best  meets  the 
requirements  of  the  case  (Figs. 
990  and  991).  If  the  stomach 
be  much  dilated,  the  duode- 
num should  be  joined  close  to 
the  greater  curvature  (Wolfler) 
(Figs.  789  and  790). 
-    ~^  The  Bemarks. — The   cavity 

of     the     stomach     should      be 
mopped  dry,  and  sponges  with 

-cr,   ocn     Ti  .  T>>        strong  attachments   introduced 

riG.  9sn. — Ihe  operati'ii  tomv.     Duo-  » 

denum  implanted  at  center  of  pyloric  division.       for      support      and     cleanliness, 


Fig.  988. 


Pylorectomy  for  carcinoma  of 
the  pylorus. 


OPEltATlUXS   UN    VlSCKllA    CUXNECTEl)    WITH    I'KlilTON.EL'M. 


73 


Fio.  990. — The  operation  of  pyloreetoinj'.      Duodenum 
implanted  at  line  of  lesser  curvature. 


being  romovod  as  the  closure  jirogrcsscs.     Curved  needles  for  sewing  the 
inner,  and  straight  for  union  of  the  outer  surfaces,  are  the  best.     The  avoid- 

,^^.  anee  of  folds  or  puckering 

<X  '  of    the    line   of    union    is 

■^^^^^"^  essential    to    its    security. 

The  sutui'ing  together  of 
the  divided  borders  is 
facilitated  by  partial  sec- 
tion and  sewing  instead  of 
complete  division  before 
suturing,  for  thus  better 
command  of  the  parts  is 
secured  and  more  rapid 
and  effective  work  per- 
formed ;  also,  leaving  some 
of  the  sutures  long  for  clamping  and  support  assists  materially  in  the  union 
of  the  parts.  The  joining  of  the  parts  by  simple  sewing  is  a  longer  though 
more  substantial  method  of 
procedure  than  by  means  of 
mechanical  expedients.  There- 
fore, the  condition  of  the  patient 
and  the  experience  of  the  opera- 
tor count  for  much  in  the  selec- 
tion of  the  best  means  of  union 
in  individual  cases.  Absorbable 
tubes  and  bobbins  and  Murphy's 
button  are  the  mechanical  ex- 
pedients which  are  regarded  as 
serviceable  substitutes  for  sew- 
ing, on  special  occasions.  Greig 
Smith  regarded  the  absorbable  tube  as  the  best  agent  of  union  in  those  cases 
in  which  the  disease  is  of  a  limited  extent  and  involves  the  duodenum  rather 

than  the  stomach,  and  in  which  the  divided 
borders  of  the  viscera  can  be  approximated 
without  undue  traction.  A  curved  decalci- 
fied bone  tube  (Fig.  992)  with  a  broader 
gastric  and  a  narrower  intestinal  end,  pro- 
vided with  an  intervening  transverse  groove 
with  perforations,  is  fastened  and  held  in 
place  by  purse-string  suturing  at  both  open- 
ings, followed  by  union  of  the  free  borders 
by  a  continuous  suture.  This  appliance 
must  be  adjusted  with  care,  and  the  mucous 
borders  inturned  and  hidden  by  carefully 
placed  scro-mupcular  sutures. 
Pylorectomy  combined  with  Gastro-enter ostomy. — This  combination  of 
methods  is  employed  especially  when  divided  borders  can  not  be  united  with 


Fig.  991. — The   operation  of   pylorectomy.     Duo- 
denum implanted  at  line  of  greater  curvature. 


Fig.  992.— The  operation  of 

rectomy.  Apposition  of  duode- 
num with  stomach  by  sutures 
over  decalcified  bone  tube. 


OPERATIVE   SURGERY. 


each  other  in  the  stereotyped  way  after  the  removal  of  the  morbid  growth. 
Kocher  regards  it  as  superior  iu  many  respects  to  the  older  plan  even  in 


Fig.  993. — The  operation  of  resection  of  the  pvhirus  and  gastro-enterostoniy.  Kocher's 
method,  a.  Duodenum,  h.  Border  of  stomach  sutured  by  a  continuous  suture 
penetrating  all  of  the  coats,  c.  United  borders  of  the  mucous  membrane  of  the 
stomach. 

cases  stiited  to  the  latter,  and  practices  it  almost  exclusively.  Czerny  favors 
reversal  of  this  order  of  procedure  by  the  doing  first  of  posterior  gastro- 
enterostomy, followed  by  resection  of  the  growth  and  closure  of  the  stomach 
and  duodenum.  Kocher  closes  the  wound  in  the  stomach  entirely  by  an 
overhand  continuous  silk  suture  carried  from  the  greater  to  the  lesser  curva- 
ture of  the  stomach  through  all  the  coats  (Fig.  99.3).  Then,  after  cleansiug 
the  uuited  borders,  the  primary  row  is  invaginated  and  covered  in  by  a 
second  row  of  continuous  Lembert  sutures  carried  through  the  sero-muscular 
walls  only.  After  all  infecting  agents  are  removed  and  the  parts  thoroughly 
cleansed,  and  the  assistant  has  grasped  the  stomach  with  both  hands  and 
pressed  it  to  the  right  (jiatient's)  so  as  to  close  the  duodenum  (Fig.  994), 
liberate  and  cleanse  the  duodenal  end,  close  the  duodenum  with  forceps  and 
apply  the  end  to  the  stomach  so  as  to  permit  of  a  ready  union  to  each  other 
of  the  posterior  Avails  of  the  viscera,  by  means  of  a  long  continuous  silk 
suture  {b)  the  ends  of  which  remain  free  ;  make  an  incision  into  the  stom- 
ach (e)  one  fourth  of  an  inch  above  the  line  of  sewing  corresponding  in 
length  to  the  width  of  the  duodenum  ;  arrest  haemorrhage,  and  unite  the 
borders  of  the  respective  organs  with  each  other  on  the  side  already  attached 
bv  a  continuous  suture  carried  through  the  walls,  or  by  a  continuous  one 


OI'KKATIOXS   ()\    VISCKKA    ('( )N.\' K(  "l'i:i)   WITH    l'i;i;i'l'(  (NMM  M. 


t  a 


carried  llirougli  the  imicous  nienibnmes  only,  and  on  tlie  opposite  side  by  a 
sero-muscular  continuous  suture;  arm  the  long,  free  extremities  of  the  pri- 
mary posterior  suture  with  needles,  aiul  therewith  supplement  the  anterior 
line  of  sewing  with  a  final  continuous  row,  including  the  serous  coats  onlv; 
thoroughly  cleanse  tlu^  })ails,  espettially  the  line  of  suture;  remove  the  pro- 
tecting gauze,  replace  the  oi-gans,  and  close  the  abdominal  wound. 

The  union  can  be  accomplished  more  quickly  by  MaiinseH's  method 
(Fig.  808),  or  by  the  absorbable  tube,  or  the  Murphy  button.  Both  duode- 
nal and  gastric  openings  can  be  closed  and  the  union  made  at  the  posterior 
surface  either  by,  1,  direct  sewing  ;  2,  Murphy's  button  ;  3,  absorbable  plates, 
tubes  and  bobbins.  If  the  space  between  the  viscera  be  too  great  for  their 
proper  apposition,  the  jejunum  can  be  joined  with  the  stomach  in  the 
manner  already  described  (gastro-euterostomy).  The  method  of  i)rocedure 
employed  should  be  selected  with  due  regard  for  the  beneficent  influence  of 


Fig.  994. — The  operation  of  pylorectdiny  aiul  irii^tro-entero^toiiiy,  Kocher's  method,  a. 
Continuous  serous  suture  closing  the  stomach,  b.  Post-serous  suture  between 
stomacli  and  duodenum,  c.  Duodenum,  d.  Assistant  closing  stomach  and  duo- 
denum by  pressure,     e.  Opening  in  posterior  wall  of  stomach. 


promptness  of  execution  and  of   experience  on  the  immediate  and  future 
outcome  of  the  case. 

.  The  Precautions. — Digital,  instrumental,  sponge  and  textile  fabric  tem- 
porary closure  of  the  openings  of  the  divided  viscera  are  each  advised  and 
practiced  with  care,  to  prevent  peritoneal  infection.  The  retention  of  a 
sponge  or  of  gauze  in  the  stomach  after  final  closure  of  the  wound  should 
be  avoided  (page  769).     The  underlying  vessels  must  be  carefully  guarded 


770  OPERATIVE   SURGERY. 

during  seisaration  of  tlie  tumor,  and  the  connecting  tissues  separated  and 
tied  singly  or  doubly  as  suits  the  circumstances  of  the  case.  The  transverse 
mesocolon  should  be  respected,  as  injury  of  it  may  result  in  impaired  circu- 
lation and  gangrene  of  the  colon.  And,  too,  gangrene  of  the  colon  may 
follow  division  of  the  omentum  at  the  greater  curvature  of  the  stomach 
(Fig.  985,  a^  a).  Deep  and  abundant  gauze  or  sponge  packing  is  impera- 
tively demanded  to  prevent  peritoneal  infection.  Small  strips  of  iodoform 
gauze  carried  around  the  line  of  suture  and  allowed  to  escape  at  the  exter- 
nal wound,  and  remaining  for  two  or  three  days  until  danger  of  leakage  has 
passed,  are  advised  by  cautious  and  experienced  surgeons  (Fig.  918).  The 
introduction  into  the  abdomen  of  sublimate  or  similar  solutions  should 
rarely  be  practiced,  as  the  use  of  absorbent  gauze  packing  and  hot  saline 
solutions  are  equally  serviceable  and  much  less  dangerous. 

The  length  of  time  required  in  many  operations  on  the  abdominal  con- 
tents, together  with  the  frequent  great  debility  of  the  patient,  bespeaks  a 
wise  selection  and  the  cautions  use  of  anaesthetics.  Chloroform  is  less  often 
followed  by  vomiting  than  is  ether.  Nitrous  oxide  in  abdominal  operations 
requiring  extended  and  careful  technique  is  highly  objectionable  because  of 
the  frequent  inability  to  control  the  spasmodic  movements  attendant  on  its 
use.  However,  the  primary  administration  of  nitrous  oxide  in  any  operation 
for  the  amelioration  or  relief  from  some  of  the  objectionable  effects  of  ether 
is  a  matter  of  quite  common  practice  in  large  towns  and  in  hospitals,  and 
offers  patients  an  escape  from  the  primary  irritation  and  some  of  the  annoy- 
ing after-effects  of  this  anaesthetic.  A  more  extended  employment  of  local 
anaesthesia  from  weak  solutions  of  cocain,  encain,  holocain,  etc.  (page  31), 
is  to  be  encouraged.  In  fact,  much  of  the  work  on  the  human  viscera  can 
be  carried  on  without  anaesthesia  with  but  little  annoyance  to  the  patient. 
The  administration  of  morphin  hypodermically  during  the  latter  part  of  an 
operation  under  ether  anaesthesia  permits  the  practice  of  much  of  the  minor 
and  final  steps  of  an  operation  without  further  use  of  ether,  thus  shortening 
considerably  the  period  of  ether  administration  (page  24).  The  free  utiliza- 
tion of  the  hot  saline  solution  in  the  prevention  and  treatment  of  shock  by 
injection  into  the  cellular  tissue  of  the  breast,  thigh,  etc.,  and  into  the  veins 
in  urgent  cases,  is  of  significant  importance  in  abdominal  operations. 

The  Remarlcs. — Pylorectomy  for  malignant  disease  is  contraindicated 
when  contiguous  tissues  are  involved  and  secondary  deposits  are  present, 
especially  when  attended  with  restricting  adhesions.  Infected  glands  and 
other  limited  involvements  should  be  removed  when  practicable.  The  ability 
to  outline  the  tumor  before  laparotomy  is  strongly  suggestive  of  an  unfavor- 
able outlook ;  the  reverse  can  be  regarded  with  favor.  Therefore,  the  scope 
of  preparation  for  operation  should  comprehend  the  accepted  methods  of 
surgical  relief  for  the  conditions  as  they  may  appear  on  exposure.  Thorough 
cleansing  of  the  stomach  and  rectal  stimulation  are  the  essential  elements  of 
routine  practice.  Eectal  alimentation  alone  should  be  practiced  for  the  first 
two  or  three  days  after  the  operation,  if  the  patient's  condition  will  permit. 
In  the  instance  of  the  use  of  the  Murphy  button,  gastric  feeding  may  begin 
at  an  earlier  date.     The  incisions  into  the  viscera  should  correspond  with 


Ol'KltATloNS   ON    NISL'EKA    (.'UNNKCTED    WITH    I'KKITUN J;UM.     777 

each  other  in  direction  and  extent  jis  nearly  as  practicable,  to  facilitate 
prompt  union  luxd  avoid  distortion.  Distorted  inij)lantatioji  and  joining  of 
the  duodenum  with  the  stomach  and  irregular  union  of  divided  borders 
should  be  sedulously  avoided  ;  all  should  be  joined  in  their  natural  outline 
with  great  care.  The  raising  and  removal  of  a  V-shaped  flap  from  the 
stomach  com})osed  of  the  sero-muscular  coats  only,  for  the  pui'pose  of  nar- 
rowing the  gastric  opening,  followed  by  suturing  of  the  (.livided  tissues  with 
each  other,  with  inversion  of  the  undivided  mucous  coat,  is  recommended  as 
a  safer  and  prompter  \)\iin  of  action  than  a  complete  division  for  the  pur- 
pose (Billroth).  In  circular  union  the  internal  employment  of  sutures  is 
better  than  the  external,  and  should  be  practiced  as  far  as  is  possible,  the 
remaining  portion  being  closed  and  the  entire  line  fortified  by  one  or  two 
rows  of  exteriud  sutures.  About  one  third  of  the  line  of  implantation  can 
be  united  by  the  internal  sewing  (Fig.  78!))  (\\'olfler).  Twenty-five  or 
thirty  round,  straight  cambric  needles,  each  armed  with  Chinese  silk,  should 
be  prepared  before  commencement  of  the  operation  (Fig.  983,  p).  Delay 
in  procedure  for  the  purpose  of  threading  needles  is  an  inexcusable  sacri- 
fice of  time  and  human  vitality.  Kochcr  regards  a  continuous  suture  carried 
entirely  through  the  borders  of  the  wound  as  the  best  primary  suture  for 
security,  control  of  bleeding,  and  expeditious  work ;  and,  further,  that  the 
use  of  clamps  adds  to  the  safety,  facility,  and  dispatch  in  operation,  and 
believes  that  no  danger  comes  to  the  tissues  from  their  use  when  they  are 
applied  only  with  needed  firmness.  Jessett  advised  the  ligature  of  the  main 
arteries  of  the  greater  and  lesser  curvatures  of  the  stomach  (Fig.  984)  just 
outside  of  tlie  limits  of  the  disease,  thus  so  controlling  the  circulation  of  the 
omenta  as  to  permit  the  ligature  of  large  segments  of  the  greater  and  tear- 
ing through  of  the  lesser  omentum,  hastening  thereby  resection.  Kocher, 
his  combined  method,  23  cases,  2  deaths.     Liicke,  7  consecutive  recoveries. 

21ie  Results. — Shock  and  perforative  peritonitis  are  the  most  frequent 
causes  of  death  associated  with  the  operation.  In  pylorectomy,  when  per- 
formed for  non-malignant  disease,  8  per  cent  died  from  the  operation ;  for 
malignant  disease,  25  to  53  per  cent,  according  to  different  estimates.  In  59 
cases  of  recovery  the  average  length  of  life  was  eleven  months  and  four  days 
(Richardson).  Of  130  cases  done  prior  to  1892,  the  rate  of  mortality,  as  based 
on  the  extent  of  the  adhesions, varied  as  follows:  No  adhesions,  50  per  cent; 
slight  adhesions,  60  per  cent ;  and  numerous  adhesions,  97  per  cent  (Schramm). 
According  to  later  estimates,  with  no  adhesions  the  rate  of  mortality  was  27.2, 
and  with  extensive  adhesions  72.7  per  cent  (Wolfler).  Even  better  results 
than  these  are  stated  in  rare  instances  in  the  experience  of  renowned  opera- 
tors.    Mil-ulicz,  10  cases,  1  death,     Krunleiii,  29,  with  2  deaths. 

Pyloroplasty  (Heineke-Mikulicz). — The  term  pyloroplasty  is  applied  to 
the  operation  for  the  relief  of  stenosis  of  the  pyloric  orifice  of  the  stomach 
resulting  from  non-malignant,  morbid  changes.  Preparatory  washing  out  of 
the  stomach  need  not  be  practiced,  if  to  do  so  will  cause  much  distress  to  the 
patient,  as  the  contents  of  the  stomach  can  be  made  to  gravitate  to  the  car- 
diac end  by  attention  to  the  position  of  the  patient.  In  other  respects  the 
preparatory  and  precautionary  measures  of  stimulation  and  asepsis,  Avhich 


778 


OPERATIVE  SURGERY. 


are  addressed   to  abdominal   operations  for  debilitating  disease,  should  be 
carefully  2)racticed. 

The  Operation. — Make  an  incision  in  the  median  line  between  the  ster- 
num and  navel  two  to  four  inches  in  length  ;  draw  apart  the  borders  of  the 

wound  with  traction  sutures ;  raise  the 
pylorus  into  the  wound  with  the  thumb 
and  fingers,  separating  or  stretching  by 
gentle  traction  any  opposing  adhesions ; 
isolate  the  pylorus  from  contiguous 
structures  by  abundant  sponge  or  gauze 
packing  so  completely  as  to  prevent  the 
possibility  of  peritoneal  infection  from 
escaping  fluids ;  make  a  longitudinal 
incision    through   the  anterior  wall   of 

Kio.  995.— The  operation  of  pyloroplasty,   the  stomach,  midway  between  the  upper 
the  Ileineke-Mikulic'Z   method,  show-  t   ,  ,       ,  ,         ^     ,i  ^ 

ing  longitudinal  incision  of  structure,   and  lower  borders,  close  to  the  pylorus, 

sufficiently  large  to  admit  the  index 
finger ;  pass  the  finger  through  the  opening  into  the  pylorus  to  ascertain  the 
presence  and  degree  of  the  obstruction  ;  remove  the  finger  and  extend  the 
incision  outward  directly  through  the  diseased  parts  into  the  healthy  duode- 
num (Fig.  995)  ;  draw  apart  the  borders  of  the  wound  with  traction  sutures 
carried  through  the  entire  thickness  of  the  walls  at  the  middle  of  either  side 
of  the  wound,  thus  changing  the  outline  of  the  wound  from  a  longitudinal 
to  a  transverse  direction ;  introduce  the  stitches  as  indicated  in  the  cuts 
(Figs.  990  and  997),  and,  if  practicable,  omit  the  tying  until  all  are  in  place; 
add  to  the  interrupted  row  of  sutures  a  supplementing  continuous  one  di- 
rected to  the  serous  coat  only ;  cleanse  and  return  the  parts  to  the  normal 
site ;  remove  the  packing  and  close  the  abdominal  wound  in  the  usual  man- 
ner, if  desirable. 

The  Remarks. — The  length  of  the  entire  incision  is  about  two  inches. 
The  tissues  of  the  borders  of  the  incision  may  be  so  rigid  as  to  require  quite 


Pig.  996. — The  operation  of  pyloroplasty, 
the  Heineke-Mikulicz  method,  showing 
sutures  placed  for  transverse  approxi- 
mation of  the  longitudinal  incision. 


Pig.  997. — The  operation  of  pyloroplasty, 
the  Heineke-Mikulicz  method,  clearly 
showing  union  of  borders  and  in- 
creased capacity  of  duodenum. 


vigorous  manipulation  to  change  the  direction  of  the  wound  and  properly 
appose  the  borders.  Splitting  the  borders  of  the  hypertrophied  tissues  along 
the  line  of  incision  so  as  to  form  a  musculo-mucous  flap  within  and  a  sero- 


OI'KUATIONS   ON    XISCKUA    CONN  MCI' I'M)   WITH    I'lOKlTOXyEUM.     779 

musonhir  itiu'  without,  aiul  uiiitiiig  tlie  inner  ones  together  with  continuous 
ciitgut  iind  the  outer  with  continuous  or  interrupted  silk  sutures,  is  advised 
by  (fr('i(/  Siiiif/i  in  cases  with  densely  thickened  borders.  If  the  structure  be 
exceedingly  dense  and  uuniaiuigeable,  the  incision  through  it  may  be  made 
of  a  diamond  shape  followed  by  removal  of  the  included  part.  This  course 
makes  the  transverse  coaptation  easier,  as  can  be  readily  seen.  (I'reif/  Smith 
regards  the  use  of  the  absorbable  tul)e  in  the  lumen  of  much  weight  in  the 
cases  complicated  with  rigid  walls  of  limited  extent,  and  advises  that  the 
mucous  and  the  remaining  coats  be  sewed  by  a  continuous  suture  independ- 
ently of  each  other.  He  regards  this  appliance  as  important,  because  it 
furnishes  an  opening  from  the  outset  and  prevents  constriction  during  heal- 
ing. Oozing  only  should  be  controlled  by  sewing;  other  forms  of  bleeding 
by  ligature.  If  infection  of  the  wound  has  taken  place  and  doubtful  cleans- 
ing be  suspected,  complete  closure  of  the  abdomen  should  be  suspended  and 
iodoform-gauze  tents  inserted  for  two  or  three  days,  after  which  they  are 
removed  and  the  abdomen  closed. 

The  ResnUs. — The  general  rate  of  mortality  of  the  operation  is  about 
21  per  cent.  Better  results  than  this  (7  per  cent.  Carle)  are  reported  at 
a  late  date.  The  final  outcome,  though  not  entirely  satisfactory,  is  much 
superior  to  that  of  divulsion  of  the  stenosis.  Formerly  the  simplicity  of 
the  operation  and  its  comparatively  low  rate  of  mortality  commended  highly 
the  practice,  but  the  later  development  of  gastro-enterostomy  supplemented 
by  the  Murphy  button,  and  the  fickleness  of  the  relief  of  the  former,  have 
lessened  its  favor  with  most  surgeons. 

Divulsion  of  the  Pylorus  (Loreta). — Lorefa\s  operation  is  applicable  to 
non-malignant  stenosis  only,  and  can  be  accomplished  by  digital  or  instru- 
mental force. 

T/ie  Operation. — The  operation  is  similar  in  all  essential  points  to  that  of 
pyloroplasty  until  after  the  stomach  is  incised  longitudinally  or  vertically 
inside  the  seat  of  the  stricture.  Then  introduce  the  index  and  middle 
fingers  of  the  right  hand  into  the  stomach ;  push  slowly  and  with  care 
through  the  stricture  the  end  of  the  middle  finger,  steadying  the  pylorus 
with  the  thumb  and  finger  of  the  left  hand  applied  without ;  raise  upward 
the  pylorus  with  the  middle  finger  and  insinuate  cautiously  the  index 
finger  by  the  side  of  the  middle,  carefully  observing  if  dangerous  tension 
be  made  on  the  outer  coats  of  the  gut;  introduce  the  ring  finger  care- 
fully by  the  side  of  the  two  already  inserted,  if  the  act  be  consistent  with 
the  maintenance  of  the  integrity  of  the  wall  of  the  viscus ;  withdraw  the 
fingers  from  the  strictured  part  in  the  order  introduced,  and,  after  a  brief 
period,  reinsert  in  like  manner  as  before,  noting  if  undue  resiliency  of  the 
stretched  tissues  be  present.  If  the  caliber  remain  dilated  to  a  proper  degree, 
withdraw  the  fingers  from  the  stomach.  If  undue  resiliency  cause  objection- 
able closure,  further  stretching  is  made  by  a  reintroduction  and  separation  of 
the  fingers  before  the  final  withdrawal.  On  withdrawal  of  the  fingers,  observe 
through  the  opening  if  active  bleeding  of  ruptured  tissues  be  present.  If  so, 
introduce  into  the  dilated  channel  the  index  finger,  while  covered  with  asep- 
tic gauze  saturated  with  a  hot  saline  solution,  and  hold  it  there  for  a  time 


780  OPERATIVE  SURGERY. 

while  firm  circular  compression  is  made  upon  it  from  without.  After  the 
arrest  of  bleeding,  close  the  opening  into  the  stomach  by  sewing  in  the  man- 
ner usual  in  sero-muscular  strictures.  Eemove  the  packing,  cleanse  the 
parts,  and  close  the  abdomen  carefully,  unless  fear  of  infection  sanctions  the 
temporary  use  of  gauze  tents.  The  final  dressing  is  then  applied,  and  the 
patient  nourished  by  the  bowel  for  the  first  three  or  four  days,  after  which 
light  fiuid  food  in  small  amounts  is  given  by  the  mouth  ;  solid  food  is  not 
taken  before  the  tenth  or  twelfth  day.  Instrumental  dilatation  offers  no 
advantages  over  the  digital,  unless  the  stricture  be  too  small  to  admit  the  end 
of  the  finger.  In  such  cases  the  use  of  instruments  should  precede  that  of 
the  fingers  and  cease  when  the  finger  is  safely  available  for  the  purpose. 

The  Remarks. — The  normal  pyloric  orifice  will  admit  quite  readily  the 
extremity  of  an  ordinary  sized  index  finger.  The  pylorus  may  be  bound 
down  more  or  less  immovably  by  adhesions  and  somewhat  obscured  by 
diseased  structural  changes.  The  gastric  incision  is  made  vertically  or  longi- 
tudinally ;  the  former  is  thought  to  be  attended  with  less  hemorrhage  and 
is  made  by  cutting  with  scissors  a  longitudinal  fold,  raised  with  the  thumb 
and  fingers.  Complete  isolation  of  the  pylorus  from  the  peritoneal  cavity 
by  gauze  or  sponges  should  precede  the  opening  of  the  stomach. 

Tlie  Precautions. — The  usual  precautions  against  infection  from  the 
escape  of  gastric  fluids  must  be  practiced.  Force  should  be  cautiously  em- 
ployed and  the  pyloric  structure  carefully  observed  to  detect  the  presence  of 
ruptures  which  may  not  be  lightly  treated.  All  hemorrhage  should  be 
arrested  and  lacerations  repaired  by  sewing  before  final  closure  of  the  ab- 
dominal wound.  Cautious  dilatation  is  necessary,  as  in  some  instances 
unsuspected  tissue  changes  may  permit  extensive  rupture  as  the  end  of  the 
finger  is  being  forced  into  the  strictures.  If  the  stomach  be  greatly  dilated, 
the  location  of  the  pyloric  opening  may  be  difficult  and  perhaps  impossible. 
In  this  instance  pyloroplasty  or,  preferably,  gastro-enterostomy  should  be 
practiced  at  once,  if  the  patient's  condition  will  permit ;  if  not,  gastrostomy, 
with  subsequent  gastro-enterostomy  should  be  considered.  The  attempt  to 
force  the  end  of  the  finger  through  a  too  small  constriction  should  give  way 
to  the  primary  use  of  a  small  catheter  or  bougie,  for  obvious  reasons. 

The  Results. — Hemorrhage,  rupture,  and  shock  are  common  causes  of 
death  from  the  operation.  Keturn  of  the  stricture  is  always  to  be  feared, 
the  same  as  in  urethral  stricture  when  treated  on  similar  principles.  Obstruc- 
tive symptoms  have  returned  in  rare  instances  within  a  week  after  the 
operation.  The  general  rate  of  mortality  appears  to  be  from  33.3  (Kinnicutt 
and  Bull)  to  40  per  cent  (Barton),  which  seems  much  too  high  for  the  appar- 
ent magnitude  of  the  operation.  At  all  events,  the  high  death  rate  and  the 
uncertainty  of  cure  do  not  inspire  unbiased  judgment  in  its  favor,  especially 
when  pyloroplasty,  and,  better  still,  gastro-enterostomy,  are  alternatives. 

Dilatation  of  the  Cardiac  Orifice.— Dilatation  of  this  opening  has  been 
practiced  not  infrequently  with  success  for  the  relief  from  stricture  there 
and  also  at  the  lower  part  of  the  esophagus.  The  description  of  the 
technique  will  be  found  under  the  treatment  of  oesophageal  stricture  (page 
600  et  seq.). 


()1M:HATI()NS   on    VISCHKA   CONNKCTKD    with    i'KRlTUX-KLM.     781 


Gastro-gastrostomy  ( (I'dsfru-coiastoniusiti). — rjiistro-gastrostoiny  is  prac- 
ticeil  for  ii'lief  fioiii  tlu-  iullictiou  of  hoiir-ghiss  contraction  of  the  stomach. 
Wijljfer,  tiirough  an  in- 
cision in  the  meiliun  line 
and  with  aseptic  precau- 
tions, exposed  the  de- 
formed stomach,  and 
made  an  opening  of  am- 
ple size  to  afford  ready 
transmission  of  the  con- 
tents  of   the   organ   into 

each   of  the  pouches,  cor-    pj^,_  <,|)H._'riH'  ..pt-raUoii  of  gastro-giistrostomy.  Wolfler's 
responding   as    nearly    as  metliud,  sliowing  the  corresponding  openings. 

practicable  to  the  greater 

curvature  (Fig.  998).     He  united  together  the  corresponding  borders  of  the 
openings  by  means  of  his  characteristic  method  of  sewing  (page  622,  Fig. 

999)  similar  viscera,  and 
thus  relieved  the  patient 
from  the  effects  of  the 
infirmity. 

The  Results. — Ap- 
parently six  instances 
of  this  method  of  prac- 
tice are  noted,  all  but 
one  of  which  recovered 
Fig.  999.— Tlie  operation  of  gastro-gastrostoniy.  W61fler"s  from  the  operation,  and 
method,  showing  suturing  of  the  borders  of  the  open-     _         .       ,  ,, 

mouths  subsequently. 
Watson,  at  a  more  recent  date  and  in  a  more  decided  case  of  contraction 
(Fig.  1000),  practiced  the  following  plan :    The  two  pouches  were  folded 
upon  each  other,  and  the  corresponding  borders  of  a  limited  area  of  the 
apposed    surfaces   were   sutured   to- 
gether (Fig.    1001),  the   sutures   at 
each  end  of  union  remaining  long  to 
indicate  the  lines  of  sewing  (/,./",./)■ 
The    anterior    wall    of   the   anterior 
pouch  was  then  incised  longitudinal- 
ly (.(/,//)  at  a  point  opposite  to  the        """^HuLiiiiB'""'  1 
previously  united  surfaces,  thus  af- 

fording   opportunity  for  division  or  " 

the  contiguous  walls  of  the  apposed    Fig.  1000.— The  operation 


tomy,  Watson's  inetlmd 


outlines  of  anastomoted  openings. 


j:i~i  iii-gastros- 
luwing  dotted 


pouches  at  a  point  within  the  cir- 
cumscribed area  of  sewing.  The 
anterior  incision  was  then  closed,  the  remaining  extremities  of  the  long 
sutures  were  cut  off  short,  and  the  borders  of  the  abdominal  wound  united 
in  the  usual  manner.  The  result  in  this  instance  was  satisfactory  in  all 
respects.     Watson's  abdominal  incision  is  unlike  Wolfler's. 


Y82 


OPERATIVE   SURGERY. 


Fig.  1001. — The  operation  of  gastro-gastrostorar, 
Watson's  method,  a.  (Esophagus.  c.  Car- 
diac end  of  stomach,  e.  Pylorus,  d.  Con- 
stricted portion.  f,f,f.  Ends  of  long  sutures. 
g,  g.  Sutured  incision  through  anterior  wall. 


Tlie  Remarks. — If  pyloric  obstruction  is  })resent  in  these  cases,  gastro- 
enterostomy is  indicated,  and  preferably  at  the  cardiac  pouch.  Weir  re- 
gards double  gastro-enterostomy 
as  preferable  to  gastro-gastros- 
tomy  in  these  cases.  In  the  in- 
stance of  adhesions  preventing 
the  apposition  characteristic  of 
the  latter  method,  the  former 
should  be  practiced.  About  17 
per  cent  die  from  the  operation. 
Gastroplasty. — In  gastroplas- 
ty the  jjrinciples  and  methods  of 
action  utilized  to  overcome  the 
constricted  portion  of  the  stom- 
ach are  identical  with  those 
employed  at  the  pylorus  for  a 
similar  purpose.  Consequently 
the  needs  for  the  practice  of  gastroplasty  are  fittingly  expressed  in  the  con- 
sideration of  pyloroplasty  (page  777).  Watson  reports  17  cases  with  3  deaths. 
Gastroplicatioii. — The  operation  of  gastroplication,  also  called  gastror- 
rhaphy,  consists  in  diminishing  the  size  of  a  permanently  dilated  stomach 
by  doubling  in  a  portion  ^ 

of  the  wall  and  suturing 
together  the  apposing 
surfaces. 

Bircher,  after  care- 
fully emptying  and  wash- 
ing out  the  stomach, 
made  an  oblique  incision 
over  the  cardiac  portion 
of  the  organ,  six  inches 
in  length,  parallel  with 
and  about  an  inch  and  a 
half  to  the  right  of  the 
cartilages  of  the  ribs. 
Through  this  incision 
the  peritonseum  was  ex-  j 
posed  and  opened  with  ; 
strict  aseptic  precau- 
tions. The  edges  of  the 
wound  were  drawn  asun- 
der,   the    stomach    was 

caught,  raised  well  up  into  the  wound,  the  anterior  surface  depressed  by 
means  of  a  long  forceps,  the  greater  curvature  seized,  carried  upward  over 
the  forceps,  and  stitched  to  the  lesser  curvature  by  thirty-five  silk  sutures 
(Fig.  1002)  so  passed  as  to  include  only  the  serous  and  muscular  coats. 
The  stomach  was  returned  and  the  abdominal  wound  closed  at  once.     The 


Fig.  1002. — The  operation  of  gastroplication, 
method,  a,  d.  Line  of  union,  b.  (Esophagus 
denum. 


Bircher's 
c.  Duo- 


Ol'KUATlONS   UN    VlSt'KIiA   CUNNKCTED   WITH    i'EKiTuN.KL'M.     783 


patient  was  nourished  by  the  bowel  for  six  days,  was  up  on  tlie  twelfth,  and 
made  an  uneventful  recovery  (Fig.  100;}). 

Weir,  without  knowledge  of  Hircher's  achievement,  practiced  gastrojjli- 
cation  on  a  patient  on  whom,  twenty-seven  months  before,  a  successful  ante- 
rior gastro-enterostomy  had  been  done  by  himself  for  relief  of  pyloric  steno- 
sis. Weir  opened  the  abdomen  in  the  line  of  the  old  cicatrix  for  five  inches, 
drew  apart  the  borders  of  the  opening,  seized  the  stomach  and  pulled  it  up 
out  of  the  wound  as  far  as  practicable,  grasped  the  greater  curvature  and 
broke  uj)  the  adhesions  that  prevented  its  pro{)er  upturning.  Midway  be- 
tween the  greater  and  lesser 
curvatures  pressure  was  made 
on  the  anterior  surface,  in  the 
long  axis  of  the  organ,  with  a 
sound  sutHcieut  to  cause  at 
either  side  longitudinal  ridges 
of  the  stomach  wall,  which 
were  united  together  over  the 
sound  for  six  or  eight  inches 
with  interrupted  silk  sutures, 
including  the  sero  -  muscular 
coats.  Additional  rows  of  su- 
tures were  applied  successively, 
each  in  a  similar  manner  to 
the  first,  thereby  forming  a 
double  fold  of  the  stomach 
equal  in  width  to  that  of  the 
hand.  The  after-treatment  of 
this  patient  was  not  dissimilar  from  that  of  Bircher's,  and,  like  his,  made  a 
prompt  recovery. 

Moynihan  applied  to  the  sero-muscular  coats  of  the  anterior  wall,  from 
the  cardiac  to  the  pyloric  extremities  of  the  organ,  a  series  of  purse-string 
sutures,  which  when  tied  caused  sufficient  inrolling  of  the  wall  to  reduce  the 
stomach  to  suitable  dimensions.  The  consequent  bulgings  at  either  end 
were  so  "rounded  off"  by  means  of  other  sutures  as  to  perfect  the  outline  of 
the  organ.  This  patient  had  an  uneventful  recovery.  Brandt  sutured  the 
anterior  and  posterior  walls,  using  over  two  hundred  sutures,  and,  notwith- 
standing the  length  of  the  procedure,  the  patient  made  a  satisfactory  recovery. 

The  Bemarks. — The  utility  of  this  operation  is  as  yet  uncertain,  except 
perhaps  in  those  cases  in  which  relief  is  not  afforded  by  pyloroplasty  or 
gastro-enterostomy,  and  in  these  cases  final  outcome  is  not  yet  established. 
This  operation  should  not  be  done  in  cases  while  suffering  from  obstruction 
at  the  pylorus.  The  use  of  gastroscopy,  gastrodiaphany  (translumination), 
and  skiagraphy  is  important  in  recognizing  structural  changes  of  the  stom- 
ach. Einhorii's  plan  of  translumination  is  serviceable  in  locating  the  curvar 
tures  of  the  organ  and  determining  the  presence  and  extent  of  neojilasmatic 
and  other  kinds  of  thickening  of  the  anterior  surface.  Bobson  reports  28 
operations  with  2  deaths.     The  death  rate  of  the  operation  is  7  per  cent. 


Fi(i.    lOOo.  —  The    operation    of     gastroplication, 
Bircher's  method.     Longitudinal  section. 


7S4  OPERATIVE  SURGERY. 

Gastropexy. — Duvet  i'e})orted  iu  189G  a  case  iu  which  he  had  opened  the 
abdomen  and  restored  a  dihited  and  distended  stomach  to  its  proper  position 
by  suturing  the  duodenum  and  the  lesser  curvature  of  the  stomach  to  the 
abdominal  wall.  Since  then  Davis  has  reported  two  cases  of  a  like  nature, 
in  which  the  patients  were  relieved  by  a  somewhat  similar  method  employed 
by  himself.  Further  knowledge  of  the  permanency  of  the  fixation  and  of 
remedial  relief  is  essential  to  establish  its  status.     In  5  cases  all  recovered. 

Gastrectomy. — The  term  gastrectomy  relates  to  the  removal  by  cutting 
of  the  whole  or  of  any  part  of  the  stomach,  therefore  partial  and  complete 
gastrectomy  are  proper  expressions. 

Partial  Gastrectomy. — The  removal  of  a  limited  portion  of  the  stomach 
for  the  cure  of  ulcer,  tumor,  etc.,  comes  under  this  heading. 

Gastric  Ulcer. — It  is  estimated  that  gastric  ulcer  occurs  in  from  4  to  5 
per  cent  of  the  entire  population  (Ewald),  and  that  the  rate  of  mortality 
from  perforation  and  hemorrhage  is  6.5,  and  3  to  4  per  cent  respectively. 
A  knowledge  of  the  usual  situation  of  gastric  ulcer  and  of  the  most  frequent 
seat  of  disastrous  involvement  is  of  great  importance  in  detecting  tlie  lesion 
and  determining  the  prognosis.  In  T93  cases  analyzed  by  ]\'elch,  it  appeared 
that  the  lesser  curvature  was  invaded  in  36.8  per  cent,  the  posterior  wall  in 
29.6,  the  pylorus  in  12,  the  anterior  wall  in  8.7,  the  cardia  in  6.3,  the  fundus 
in  3.7,  and  the  greater  curvature  in  3.4  per  cent  of  the  cases.  It  is  exceed- 
ingly important  to  note  the  facts,  that  although  ulcer  of  the  posterior  surface 
of  the  stomach  is  three  and  a  half  times  more  frequent  than  at  the  anterior 
surface,  perforation  happens  much  oftener  and  is  more  acutely  dangerous  at 
the  anterior  than  at  the  posterior  aspect  of  the  organ.  Brinton  estimates 
that  posteriorly  2,  anteriorly  85,  at  the  cardiac  end  40,  at  the  pylorus  10,  and 
at  the  lesser  curvature  18  in  every  100  perforate.  In  view  of  the  compara- 
tive relations  of  the  seats  of  perforation.  Keen  emphasizes  the  wisdom  of  a 
methodical  search  for  the  lesion,  "  beginning  first  with  the  anterior  wall, 
next  the  cardia,  then  the  lesser  curvature  to  the  pylorus,  and  ending  the 
search  with  the  posterior  wall."  Inasmuch  as  two  or  more  ulcers  are  present 
in  a  fifth  of  all  the  cases,  the  detection  of  a  single  perforation  should  suggest 
the  presence  of  still  another  where  perforation  is  impending  or  complete. 
Usually  the  ulcer  perforates  into  the  greater  peritoneal  cavity  (Fig.  940,  c), 
causing  early,  pronounced,  and  extensive  peritonitis.  Sometimes  it  opens 
into  the  lesser  peritoneal  cavity  (Fig.  940,  h)^  producing  less  pronounced 
manifestations,  but  often  followed  by  abscess  of  the  subphrenic  type. 

Operation  for  Perforated  Ulcer. — The  indications  for  treatment  are  self- 
evident  and  should  be  carried  into  effect  without  delay.  Nothing  whatever 
should  be  introduced  into  the  stomach  except  perhaps  the  tube  of  a  pump 
when  the  organ  is  filled,  to  remove  the  contents,  which  should  be  carefully 
done  without  flushing.  Under  chloroform  anaesthesia  (page  24)  make  an 
incision  along  the  umbilicus  in  the  median  line,  or  vertically  to  the  left  of 
this  point,  as  may  seem  best  at  the  time,  enlarging  it  transversely  to  the  left 
when  required  for  better  exposure  and  treatment  of  the  cardia,  open  the 
peritonseum  freely,  separate  widely  the  borders  of  the  wound  with  retractors 
and  expose  the  operation  field  to  a  strong  light. 


uim:i:a'I'I().\s  on  visckra  connkctki)  with  i'kui'I'ox.kl'm.    735 

Tlie  o])L'uiiig  of  the  periloiiunim  is  sometimes  uttemled  with  tlie  escape 
of  gas  and  iluids,  confirmatory  at  once  of  })erforation.  If  extravasated  fluids 
be  present  they  should  be  wiped  awuy  (carefully  before  further  numipulation 
is  attempted,  and  as  search  is  made  tiiey  are  removed  as  fast  as  tiiey  appear 
to  prevent  infection.  If  Ihiitls  are  not  present  or  are  of  small  amount  and 
circumscribed,  the  prospec^ts  are  correspondini^ly  ffivorable.  In  either  in- 
stance the  contiguous  tissues  should  be  carefully  protected  by  gauze  j)ads  or 
ilat  sponges  before  the  stomach  is  handled.  Examine  closely  and  cautiously 
the  anterior  surface  of  the  stonuich,  utilizing  as  guides  to  the  defect  escaping 
fluids,  deepening  areas  of  congestion,  adherent  lymph,  and  the  sense  of  indu- 
ration indicative  of  the  base  of  the  ulcer.  The  liver  should  be  raised  up- 
ward, the  stomach  i)ulled  downward  and  forward  by  gentle  traction  on  the 
omentum,  ami  adhesions  cautiously  broken  up  wlien  necessary  for  complete 
observation.  The  opening  is  securely  controlled  by  pressure  or  plugging 
as  soon  as  discovered,  the  parts  are  thoroughly  cleansed  by  wiping,  and  the 
stomach  is  raised  well  u()  into  the  wound,  isolated  still  more  with  gauze  pads, 
etc.,  and  repair  is  made  by  either  of  the  following  methods  : 

Inversion  of  the  borders  of  the  perforation  and  closure  of  the  opening 
with  one  or  two  rows  of  Lembert  sutures,  the  same  as  in  typhoid  ulcer  (page 
7'28).  The  Halsted  suture  is  especially  serviceable.  Care  should  be  taken 
to  invert  the  entire  nicer  and  provide  at  its  border  tissues  of  suflRcient 
strength  to  permit  of  firm  and  secure  union.  Excision  of  the  ulcer  length- 
ens the  time  of  the  operation  without  a  commensurate  reward  in  the  major- 
ity of  instances.  Careful  search  should  be  made  to  detect  the  presence  of  a 
second  perforation,  and  the  indications  of  a  prospective  one  before  the  stom- 
ach is  returned  to  the  abdomen.  In  some  instances  it  is  exceedingly  diffi- 
cult to  locate  the  opening  because  of  its  small  size  or  obscure  location.  An 
nicer  of  the  posterior  wall,  when  otherwise  inaccessible  to  examination 
because  of  adhesions,  may  be  detected  through  the  anterior  wall  by  the  fin- 
ger. In  an  instance  of  this  kind  Kuster  cauterized  the  ulcer  and  then  per- 
formed gastro-enterostomy  with  a  successful  issue. 

When  it  is  impossible  because  of  thickness  or  rigidity  of  the  walls  of 
the  stomach  or  the  presence  of  resistant  adhesions,  or  the  size  of  the  open- 
ing, to  apply  the  preceding  method  of  cure,  that  of  Barker  and  Dalziel  may 
be  utilized.  After  excision  of  the  ulcer  the  borders  of  the  mucous  membrane 
and  of  the  ulcer  are  brought  into  contact  with  each  other  independently  by 
sutures.  In  the  two  instances  in  which  this  plan  was  practiced  prompt 
recovery  ensued.  Keen  suggests  that  greater  security  might  be  obtained  by 
supplementing  the  line  of  union  by  the  omental  graft  of  Senn.  In  these 
cases,  when  the  edges  can  not  be  approximated,  Bennett^  in  a  case  of  perfora- 
tion of  three  inches  diameter,  and  surrounded  by  indurated  borders  making 
sewing  impossible,  plugged  the  opening  with  omentum,  which  he  fixed  in 
place  at  the  borders  with  four  or  five  sutures  and  overlapped  the  whole,  as 
far  as  possible,  with  Lembert  sutures.    This  patient  made  a  prompt  recovery. 

Braun,  in  a  case  of  perforation  in  which  the  borders  of  the  opening 
could  not  be  sutured  together,  nor  to  the  abdominal  wound  because  of  their 
thin,  fragile,  and  highly  vascular  state,  patched  the  opening  with  omentum 


786  OPERATIVE  SURGERY. 

by  interrupted  sutures  and  performed  gastro-enterostomy.  This  patient  left 
the  hospital  in  five  weeks  and  a  half  "free  from  trouble." 

Haward,  in  a  case  of  collapse  from  perforation  and  in  which,  because  of 
great  infiltration  and  thickening  of  the  stomach,  he  was  unable  to  practice 
excision  of  the  ulcer,  sutured  the  margins  of  the  ulcer  to  the  borders  of  the 
abdominal  incision,  and  introduced  a  drainage  tube  into  the  stomach.  This 
jDatient  died  six  weeks  later  from  purulent  processes  at  the  bases  of  the  lungs. 

Paul.,  in  a  case  in  which  he  was  unable  to  carry  into  effect  any  form  of 
suturing  because  of  the  dependent  position  of  the  ulcer  and  the  existence  of 
extensive  adhesions,  resorted  to  free  drainage  of  the  stomach  by  means  of  a 
tube  introduced  through  the  abdominal  wound  into  the  perforation,  and  so 
confined  and  surrounded  with  gauze  as  to  conduct  the  contents  of  the 
stomach  to  the  outside.  Somewhat  later  a  limited  number  of  cases  have 
received  similar  treatment,  the  majority  of  which  recovered.  It  seems  prob- 
able that  in  these  latter  cases  either  the  omental  plug  of  Bennett  or  the 
omental  patch  of  Braun  might  have  proved  the  better  expedients. 

After  completion  of  the  gastric  portion  of  the  procedure  infinite  care 
must  be  taken  to  thoroughly  cleanse  the  peritonaeum,  otherwise  the  most 
skillful  technique  will  fail  to  save  the  life  of  the  patient. 

The  Precautiojis. — When  perforation  is  suspected  the  patient  should  be 
caused  to  lie  quietly  on  the  back  and  shallow  breathing  should  be  encour- 
aged and  even  secured  when  practicable  by  limiting  the  movements  of  the 
diaphragm.  Talking,  coughing,  and  all  needless  efforts  should  be  avoided. 
The  preparations  for  operation  should  be  commenced  at  once,  so  that  prompt 
action  may  follow  diagnosis  and  perhaps  establish  it  by  explorative  incision. 
The  use  of  the  stomach  pump  should  in  no  way  hinder  or  delay  prepara- 
tions of  operative  procedure.  The  needs  for  stimulation  by  the  most 
approved  methods  should  be  anticipated  and  provision  made  for  prompt 
utilization.  Finally,  it  should  be  indelibly  impressed  that  the  additional 
advantages  of  early  operation  may  be  sacrificed  by  incomplete  preparation, 
inadequate  provision  for  suitable  observation,  peritoneal  cleansing,  and  the 
combating  of  shock.  Observation  of  the  pelvic  cavity  should  be  carefully 
practiced,  and  suitably  located  drainage  provided  in  dependent  situations 
when  indicated  by  marked  infection.  Narrowing  of  stomach  orifices  should 
be  avoided. 

The  Results. — Those  cases  operated  on  before  1896  and  within  the  first 
twelve  hours  show  a  mortality  rate  of  39.18  per  cent  (  Weir  and  Foote)  and 
28.57  per  cent  (Keen).  The  operations  since  that  time  give  a  rate  of  16.66 
per  cent  {Keen).  In  operations  within  twelve  hours  afterward  (twelve  to 
twenty-four  hours)  the  rate  of  mortality  is  more  than  doubled. 

Operation  for  Non-perforating  Ulcer. — Relief  from  this  variety  of  ulcer 
may  be  had  by  means  of  operations  that  secure  rest  for  the  disease,  and  by 
excision  of  the  disease  and  closure  of  the  wound  by  sewing.  The  attain- 
ment of  the  former  aim  is  reached  by  pyloroplasty  and  by  gastro-enteros- 
tomy. Keen  favors  the  latter  because  of  the  "  speedy  emptying  of  the  con- 
tents of  the  stomach  "  and  the  consequent  securing  of  rest.  Pyloroplasty 
is  practiced  by  Morison  and  Mikulicz,  each  of  whom  scrubbed  the  ulcer 


OPERATIONS   ON    VISCKKA    t'ONNECTKI)    WITH    I'KHI'I'ON/KU.M.     7,^7 

with  giiuzu  and  thou  ri'paircd  the  tlofuct  by  uniting  ov(U'  it  wit'n  catgut  the 
borders  of  the  mucous  mcnibriiue. 

llie  remoiutl  by  excision  (j)artial  gastrectomy)  of  a  non-perforating  and 
of  u  perforated  ulcer,  althougii  an  opei'ation  ideal  in  the  conception  and 
perfect  in  the  execution,  is  open  to  tiie  strong  objection  of  prolonging  the 
operation  without  atToi-ding  an  adequate  return  for  the  time  consumed. 
Especially  is  this  true  in  instances  of  large  ulcers:  those  surrounded  by 
pronounced  and  extensive  induration,  those  obscurely  located,  and  those 
attended  with  shock  from  perforation  or  great  depression  from  other  causes. 
However,  a  sufficient  number  of  successful  cases  of  resection  for  non-perfo- 
rating ulcer,  especially,  are  recorded  to  commend  its  employment  in  selected 
cases.     Rodman  rei)orts  10  operations  with  2  deatiis. 

Operation  for  HsBmorrhage  from  Ulcer  of  the  Stomach.— As  elsewhere 
stated  (page  784),  three  to  four  per  cent  having  ulcer  of  the  stomach  die  from 
hajmorrluige.  The  severity  of  the  bleeding  is  modified,  of  course,  by  the  size 
of  the  vessel  involved,  being  active  and  promptly  fatal  in  one  instance,  in 
another  sapping  the  patient's  strength  by  repeated  small  haemorrhages,  and 
finally  causing  death  from  exhaustion.  In  this  operation  the  stomach  is  ex- 
posed through  a  median  incision,  and  the  anterior  surface  carefully  examined 
by  sight  and  touch  for  the  vascular  and  indurative  changes  indicative  of  deep 
ulcerative  action.  The  history  of  the  case  may  not  infrequently  suggest  the 
site  of  the  morbid  process.  The  examination  is  carried  on  as  for  perforated 
ulcer  (page  785),  and  with  exceeding  caution.  External  examination  failing 
to  locate  the  site  of  the  ulcer,  a  longitudinal  incision  is  made  at  the  anterior 
surface,  midway  between  the  greater  and  lesser  curvatures,  of  sufficient 
length  to  permit  of  the  introduction  of  the  index  finger  for  conjoined 
manipulation  followed  by  an  increase  sufficient  to  afford  ready  inspection  of 
the  common  sites  of  nicer  by  aid  of  wide  separation  of  the  borders  of  the 
wound  and  a  strong  light.  If  haemorrhage  be  progressing  at  the  time  of 
operation,  little  or  no  trouble  will  be  experienced  in  detecting  the  bleeding 
site.  If,  however,  bleeding  has  already  stopped,  the  surgeon  may  be  much 
perplexed  in  finding  the  seat  of  the  lesion,  especially  when  it  is,  as  often 
happens,  of  minute  size.  The  presence  of  circumscribed  induration,  of 
increased  vascularity,  of  an  adherent  blood  clot,  and  of  defined  structural 
changes  point  to  the  seat  of  disease.  Careful  wiping  of  the  surface  with  a 
soft  sponge  will  materially  aid  in  the  search.  When  discovered,  the  margin 
of  the  ulcer  may  be  seized  with  forceps  and  brought  through  the  gastric 
opening,  remembering  that  if  the  ulcer  be  located  near  to  either  extremity 
of  the  stomach  it  will  be  wiser  to  extend  the  gastric  incision  correspond- 
ingly than  to  make  undue  and  likely  unsuccessful  traction  for  tlie  purpose 
of  withdrawal.  If  resisting  adhesions  oppose  the  traction  and  also  efforts  of 
separation  wuth  the  finger,  it  is  better  that  gastro-enterostomy  be  done  with- 
out delay.  After  proper  exposure  of  the  ulcer  it  may  be  excised,  especially 
if  small,  readily  accessible,  and  associated  with  a  large  vessel.  The  wound 
is  then  closed  by  sewing  {gastrorrhaphy)  and  the  part  returned.  It  is  evi- 
dent that  the  ligature  of  the  bleeding  points  can  not  fail  to  secure  the  vessel 
primarily  involved.  The  closure  of  the  ulcer  by  continuous  suture,  or,  if 
56 


Y88  OPP]RATIVE  SURGP]RY. 

small,  by  tying  en  masse  the  base  of  its  piiielusd-up  borders,  or  the  loosening 
by  dissection  of  the  borders  and  their  union  by  sutures,  either  of  which  places 
the  ulcer  at  rest,  may  be  practiced,  provided  that  the  vessel  involved  is 
securely  tied  outside  of  the  ulcei'ated  area.  The  tying  may  be  accomplished 
by  passing  a  ligature  around  it  from  without  or  from  within,  grasping  at  the 
same  time  a  small  part  of  the  contiguous  tissues.  In  either  instance,  greater 
security  is  had  by  burying  the  ligature  by  means  of  stitches  passed  through 
the  sero-muscular  coats.  Measures  of  the  preceding  character  are  often  open 
to  grievous  fallacies,  suggesting,  therefore,  the  need  of  great  discretion  in  their 
use.  The  high  rate  of  mortality  attendant  upon  direct  operative  practice  for 
the  cure  of  haemorrhage  in  ulcer  of  the  stomach  em})hasizes  the  wisdom  of 
the  prompt  performance  of  the  simpler  and  heretofore  more  successful  meas- 
ures, pyloroplasty  and  gastro- enterostomy,  not  only  after  haemorrhage,  but 
also  before,  in  anticipation  of  the  event,  when  medication  affords  no  prac- 
tical relief. 

Tlie  Results. — In  13  operations  for  haemorrhage,  9  deaths  ensued.  The 
results  of  partial  gastrectomy  for  ttimors  are  much  better  ;  about  85  per  cent 
surviving. 

Complete  Gastrectomy. — Complete  removal  of  the  entire  stomach  was  first 
accomplished  successfully,  September  6,  1897,  by  Carl  Schlatter,  of  Zurich, 
Before  this  time  eminent  surgeons  had  successfully  removed  almost  the 
entire  organ  on  several  occasions.  Connor,  of  Cincinnati,  effected  the  com- 
plete removal  so  long  ago  as  1883.  But  the  credit  of  the  attempt  was  hushed 
by  the  prompt  death  of  the  patient.  Since  the  announcement  of  Schlatter's  * 
case,  Brigham  f  and  McDonald,  of  San  Francisco,  and  Richardson,];  of  Bos- 
ton, have  each  reported  a  similar  result  of  their  own.  llarvie,  of  Troy,  and 
Delatour,  of  Brooklyn,  have  each  operated  successfully. 

Schlatter''s  patient  was  a  female,  fifty-six  years  of  age,  with  complete 
cancerous  involvement  of  the  stomach  and  softened  lymph  nodes  at  the 
pyloric  end. 

The  Operation. — Under  morphine-ether  anaesthesia  and  with  strict  anti- 
sepsis an  incision  was  made  in  the  median  line  from  the  ensiform  cartilage 
to  the  umbilicus.  The  tumor  was  found  to  be  freely  movable,  and  could 
be  readily  raised  out  of  the  abdominal  cavity.  The  left  lobe  of  the  liver 
was  then  raised,  the  stomach  completely  isolated  with  sterilized  compresses, 
and  the  omental  attachments  at  the  greater  and  lesser  curvatures  were 
divided  with  the  end  of  Pean's  forceps,  and  tied  with  silk  ligatures.  The 
stomach  was  dragged  downward  to  expose  the  lower  end  of  the  oesophagus, 
which  was  then  secured  high  up  by  Wolfler's  clamp.  Stille's  forceps  was 
applied  close  to  the  cardiac  aspect  of  the  tumor,  the  stomach  severed  at 
the  oesophageal  attachment,  and  the  end  of  the  oesophagus  protected  with 
iodoform  gauze.  The  duodenum  was  then  mobilized  to  as  near  the  head 
of  the  pancreas  as  possible,  and  two  compression  forceps  were  applied  to 
it  close  together,  the  inner  at  the  duodenal  aspect  of  the  tumor,  between 


*  Medical  Record,  December  35,  1897. 

f  Boston  Medical  and  Surgical  Journal,  May  5,  1898.  J  ThIiJ..  October  20,  1898. 


<)l'i:i;.\'n(>NS   ON   VISCKRA    CONNEOTKI)   WTI'll    I'KIM'l'OX/lU'.M.     789 

wliicli  the  liowcl  was  sovcrcd.  The  severed  mass  was  llieii  removed,  the 
end  (if  the  dut)(hMiiiiii  [jrotected  with  iodoform  i^aiize,  and  tlie  infected 
nudes  were  dissi'cted  away.  Since  only  with  fijreat  diniciilty  could  the  open 
end  of  the  eiuodenuin  be  made  to  touch  the  lower  end  of  the  aisophagus  it 
was  nnmifestly  iinpossible  to  unite  them  hy  direct  suture.  Therefore,  the 
duodenal  end  was  invuginated,  and  a  suitable  loop  of  the  jejunum  was  car- 
rii'd  up  in  front  of  the  colon  to  the  lower  end  of  the  oesophagus,  to  which 
it  was  connected  by  serous  sutures.  A  longitudinal  slit  an  inch  in  length 
was  made  into  tlie  bowel,  and  the  borders  of  the  mucous  membrane  of  the 
respective  openings  were  firmly  pinned  together  by  a  continuous  circular  silk 
suture;  over  this  a  second  was  carried,  including  the  sero-muscular  coats, 
followed  by  a  third  row  of  the  Lembert  variety.  The  esophageal  clamp, 
which  had  been  in  place  over  two  hours,  w'as  then  removed,  also  the  one  on 
the  duodenum.  The  abdominal  wound  was  united  in  the  usual  manner  by 
silk  sutures,  aiul  the  patient  put  to  bed.  The  operation  lasted  nearly  two 
hours  and  a  half,  and  less  than  eight  ounces  of  ether  were  administered. 
The  loss  of  blood  was  slight,  and  the  pulse  at  the  end  of  the  operation  was 
96  per  minute,  steady,  and  of  fair  volume.  This  patient  made  a  successful 
recovery.  The  after-treatment  of  the  case  is  so  important  and  extended  that 
the  reader  is  invited  to  consult  the  original  report. 

Brighani's  Case. — The  patient,  a  female  sixty-six  years  of  age,  with  can- 
cerous involvement  of  more  than  half  of  the  stomach. 

llie  Operation. — Under  chloroform-ether  anaesthesia  and  strict  anti- 
sepsis a  primary  incision  three  inches  in  length  was  made  in  the  median 
line  between  the  ensiform  cartilage  and  the  umbilicus.  The  parietal  perito- 
neum and  the  omentum  were  adhered  together  the  entire  length  of  the  inci- 
sion. The  stomach  only  was  involved.  It  was  freely  movable,  and  a  large 
mass  was  noted  at  the  pyloric  extremity.  Because  of  unusual  thickness  of 
the  abdominal  wall  the  incision  was  extended  from  the  ensiform  cartilage  to 
an  inch  below  the  umbilicus.  Complete  isolation  of  the  stomach  with  hot 
gauze,  frequently  changed  throughout  the  operation,  was  carried  into  effect. 
Commencing  at  the  greater,  both  curvatures  were  freed  from  omenta  by 
lisaturins:  with  catgut  in  half-inch  sections  for  three  or  four  inches  alter- 
nately,  thus  permitting  rotation  of  the  stomach  and  aiding  the  separation. 
The  division  at  the  lesser  curvature  was  very  difficult  because  of  the  greater 
depth  of  the  omentum  at  that  situation.  After  freeing  the  curvatures 
the  duodenum  was  closed  by  clamping  at  two  situations.  One  clamp  was 
applied  close  to  the  growth,  the  other  half  an  inch  outside  of  the  first,  and 
betw^een  them  the  bowel  was  severed.  The  distal  end  of  the  duodenum  was 
cleansed  with  a  saline  solution  and  wrapped  in  iodoform  gauze.  The 
gastro-splenic  omentum  was  then  tied  and  divided,  the  stomach  drawn 
down,  and  two  clamps  were  applied — one  just  above  the  cardiac  orifice,  the 
other  to  the  (esophagus  a  little  more  than  an  inch  above  the  preceding. 
Between  them  the  resophagus  was  divided,  and  the  end  treated  with  saline 
solution  and  wrapped  in  iodoform  gauze  and  the  stomach  removed.  The 
extremities  of  the  duodenum  and  the  oesophagus  could  be  easily  approxi- 
mated for  sewing,  but  as  the  patient's  condition  demanded  haste  a  Xo.  3 


790  OPERATIVE   SURGERY. 

Murphy  button  was  used  instead.  The  abdominal  wound  was  closed  and  the 
])atient  put  to  bed.  The  time  of  operation  was  two  hours  and  a  quarter,  the 
patient  losing  about  two  ounces  of  blood.  Chloroform  was  employed  at  the 
beginning  of  the  operation,  and  substituted  by  ether,  of  which  about  eleven 
ounces  were  administered.     This  patient  made  a  good  recovery. 

Eichardson^s  Case. — The  patient,  a  female  aged  fifty-three,  with  cancer- 
ous involvement  of  "  practically  the  whole  organ  except  a  small  portion  next 
to  the  oesophagus."     Xo  evidence  of  the  disease  found  elsewhere. 

The  Operation. — The  stomach  was  exposed  through  a  median  incision  and 
found  to  be  mobile  and  affording  ojjportunity  for  examination  of  the  pyloric 
and  oesophageal  attachments,  and  apparently  demonstrating  that  no  difficulty 
would  be  experienced  in  uniting  together  the  ends  of  the  oesophagus  and 
duodenum — a  conclusion  not  sustained  by  subsequent  effort.  In  extirpat- 
ing the  tumor  the  omentum  at  the  greater  curvature  was  tied  in  inch  sec- 
tions with  silk  for  an  inch  or  more  beyond  the  limitations  of  the  disease, 
being  divided  as  fast  as  tied,  and  the  posterior  wall  of  the  stomach  exposed. 
About  five  inches  of  the  transverse  mesocolon  were  unintentionally  included 
with  the  omentum  in  the  section  and  divided,  but  prompt  approximation  of 
the  borders  of  the  opening  by  sewing  secured  repair  without  an  unfavorable 
sequel.  The  stomach  was  raised,  isolated  with  gauze,  the  duodenum  closed 
bv  tving  with  strips  of  gauze,  and  then  severed  transversely  with  scissors. 
The  bleeding  points  were  secured,  the  lesser  omentum  was  tied  and  divided 
the  same  as  was  the  greater,  the  stomach  drawn  downward  and  outward,  the 
lower  end  of  the  (esophagus  exposed,  clamped,  and  so  divided  transversely 
as  to  form  a  bell-shaped  lower  extremity,  which  was  suitably  narrowed  by 
interrupted  sutures  for  union  with  the  open  end  of  the  duodenum.  The 
tense  retroduodenal  bands  resisting  proper  approximation  of  the  open  ends 
were  tied  and  severed,  thus  gaining  the  additional  inch  or  more  needed  for 
safe  approximation  and  union  of  the  (jesophagus  with  the  duodenum  by 
means  of  interrupted  Lembert  silk  sutures.  The  loss  of  blood  was  not  sig- 
nificant, the  shock  slight,  and  the  time  of  operation  an  hour.  The  patient 
made  a  satisfactory  recovery  from  the  operation,  but  died  from  return  of  the 
disease  in  about  nine  months. 

Tlie  General  Remarks. — The  abbreviated  details  of  the  technique  of  three 
successful  cases  of  complete  gastrectomy  are  given,  but  with  the  admoni- 
tion that  subsequent  efforts  in  the  operation  should  not  be  attempted  with- 
out careful  study  of  the  reports  of  the  successful  and  unsuccessful  cases  in 
all  of  their  bearings,  remembering  that  not  the  least  in  importance  is  the 
after-treatment. 

Wounds  of  the  Stomach. — Wounds  of  the  stomach  can  be  classified  as  are 
wounds  of  the  soft  parts  elsewhere.  The  position  and  size  of  the  wound 
and  its  outline,  coupled  with  the  amount,  nature,  and  degree  of  fluidity 
of  the  contents  of  the  stomach,  exercise  a  marked  influence  on  the  gravity 
of  the  injurv.  Also  the  liability  to  serious  complications  of  contiguous 
vessels  and  viscera  should  be  recognized,  especially  in  those  wounds  when 
arising  from  external  violence.  Whether  or  not  the  injury  be  limited 
onlv  to  the  anterior  surface  of  the  organ  or  involve  as  well  the  posterior, 


(ii'l:katio>;s  un  viscKiiA  connkctkd  with  i'i;i:iTuNj;r.M.    7m 

ought  not  to  escape  the  mind  of  the  sur<(eon.  Kor  sh(Kild  tlie  surgeon  in 
doubtful  cases  of  injury  on  mere  iissuniption  dehiy  action  so  long  that  the 
outcome  of  operative  effort  will  assume  the  phase  of  last  resort.  It  is  much 
better,  indeeil,  to  reasoiuibly  assume  the  pi-esence  of  injury,  promptly  exjjlore, 
jiscertaiu,  and  ])erlia])s  repair  a  threatening  defect  without  especial  danger, 
thus  securing  both  comfort  and  safety,  than  to  hesitate  too  long  at  the 
expense  of  both.  The  technicjue  of  repair  of  these  injuries  differs  in  no 
essential  regard  from  that  of  similar  injuries  of  the  intestine.  The  closure 
of  these  wounds  by  sewing  {(/asfrurrl/aplii/)  is  accomplished  the  same  as  that 
of  the  intestines  {eiiterorrhaphy).  The  principles  of  the  use  of  the  gauze 
pad,  isolation  of  the  injured  part,  and  of  aseptic  agents  are  identical.  The 
care  in  the  removal  from  the  peritoneal  cavity  of  infecting  agents,  secur- 
ing cleanliness,  and  the  establishment  of  drainage  are  comparatively  simi- 
lar. In  injury  of  the  stomach  the  possibility  of  infection  of  the  lesser  peri- 
toneal cavity,  especially  from  wounds  at  the  posterior  surface  of  the  organ, 
together  with  the  need  of  cautious  search  for  contiguous  complications, 
should  be  kept  clearly  in  view.  fJunshot,  incised,  and  ruptured  wounds, 
especially  of  a  plethoric  stomach,  demand  prompt  operative  practice,  even  at 
the  risk  of  deepening  the  shock.  The  employment  of  cocain  ansesthesia 
will  not  be  amiss,  especially  in  those  cases  of  shock  and  of  extended  injury 
contraindicating  the  administration  of  general  ana3sthetics,  because  of  the 
depression  and  the  physical  excitement  and  dangers  incurred  from  their  use. 

OPERATIOXS    OX   THE    LIVER,    (iALL    BLADDER,    AND    BILIARY    DUCTS. 

The  newly  devised  and  somewhat  extensive  operative  procedures  relating 
to  these  parts  of  the  human  anatomy,  together  with  the  abnormal  deviations 
incident  to  disease,  require  that  the  salient  points  of  their  relative  anatomy 
be  given  at  least  a  brief  consideration.  The  liver  alone  is  subject  to 
abscess,  hydatids,  and  various  other  morbid  growths.  It  is  liable  to  trau- 
matism of  greater  or  less  extent  and  severity.  The  complications  incident 
to  the  diseases  and  injuries  of  the  organ  are  often  of  greater  moment  than 
are  the  injuries  themselves. 

OPERATIONS    ox    THE    LIVER. 

The  Anatomical  Points. — The  lower  border  of  the  fourth  rib  corresponds 
to  the  upper  limit  of  the  liver  on  the  right  side  at  the  mammary  line;  the 
junction  of  the  sixth  rib  with  the  cartilage  lies  close  to  the  upper  and  outer 
limits  at  the  left  side  and  in  front.  The  lung  covers  the  liver  behind  down 
to  the  tenth  dorsal  spine,  or  to  about  the  ninth  rib ;  posteriorly  the  liver  lies 
behind  the  lower  ribs,  extending  from  the  eleventh  upward  to  the  fifth  or 
sixth ;  anteriorly,  at  the  right,  it  lies  behind  part  of  the  ensiform  cartilage 
and  the  costal  cartilages  of  the  fifth,  sixth,  seventh,  eighth,  and  ninth  ribs; 
in  front,  at  the  left,  it  corresponds  below  to  the  tip  of  the  eighth  costal  car- 
tilage of  that  side;  below  the  ensiform  cartilage  it  lies  superficially  and  in 
contact  with  the  abdominal  wall,  extending  downward  almost  halfway  to 
the  navel.  For  completer  detail  in  those  matters  the  reader  is  referred  to 
the  standard  works  on  anatomy.     Tlie  downward  movement  of  the  liver  and 


792 


opp:rative  surgery. 


.  ;/.J£>V  u  «i>caaOm»^£UiUK::V^ 


Va-tjuelirts  Ca^uderij 


Fig.  1004.— Instruinents  employed  in  operations  on  the  liver. 

a  Scalpels,  b.  Bistouries,  c.  Forcipress.ire.  d.  Curved  and  straight  scissors,  e.  Dis- 
■  seetin-  and  mouse-tooth  forceps.  /.  Needle  forceps.  /;.  Retractors.  *■  £P"V?e- 
holder  /.  Drainage  tube.  A".  Traction  loops.  /.  Chromicized  catgut,  n.  btraigtit 
and  curved  needles,  o.  Silkworm,  silk,  and  catgut  sutures,  p.  Large  and  small 
gauze  pads  with  tails,  q.  Hypodermic  syringe.  Sponges,  wipers,  tenacula,  cos- 
totome,  and  good  light  are  also  essential. 


OPERATIONS   ON    VlSCKlfA    CONNIKTKI)  Willi    PKRITON.KUM.     793 

the  iipwaid  :iud  outward  iiiuveiueiits  of  the  lilj-s  during  iiiripiration  suggest 
tlie  jidvisability  of  contijienient  of  the  ribs  iit  the  right  side  during  opcrutive 
l)rocedures  im  the  liver  if  the  piitieiit's  safety  will  permit.  The  thinness  of 
the  liver  eai)sule  and  the  fi'iability  of  the  liver  tissue  render  elosun^  of  wounds 
of  the  organ  a  ditlieult  and  unsatisfactory  procedure. 

Operations  for  Abscess  of  Liver. — The  operations  for  the  relief  of  this 
alTei'tiou  are  of  a  siin|)le  and  a  radical  nature,  tlie  former  being  tentative 
only  iu  many  instances. 

Aspiration. — Aspiration  in  hepatic  abscess  is  of  chief  importance  as  a 
diagnostic  measure.  As  a  tentative  act  it  removes  often  to  a  remoter  period 
the  danger  of  disastrous  rupture,  thus  affording  time  to  prepare  the  better 
for  the  use  of  severer  measures.  As  a  curative  means  little  need  be  expected 
of  it,  not  enough,  in  fact,  to  justify  delay  for  this  reason  alone. 

T/ie  Precdutioits. — Thorough  asepsis  of  the  needle  by  boiling  and  of  the 
skin  by  scrubbing,  etc.,  must  be  practiced  to  prevent  infection  of  the  liver 
directly  by  agents  connected  with  the  skin  or  lying  within  the  needle.  The 
needle  should  be  so  entered  and  directed  as  to  avoid  the  pleura,  lung,  and 
deep  vessels  of  the  liver  and  abdomen.  The  movements  of  the  right  side  of 
the  chest  should  be  made  as  quiescent  as  possible  by  mechanical  means  and 
voluntary  efforts  during  the  introduction  of  the  needle,  which  should  be  done 
at  expiration.  At  all  events,  the  outer  part  of  the  needle  should  be  permitted 
to  move  u])ward  and  downward  with  the  respiratory  acts,  to  avoid  injury  to 
the  liver  by  the  inner  part.  A  small  needle  can  be  introduced  into  the  liver 
in  various  directions  at  a  single  sitting  in  search  of  pus,  without  any  special 
danger,  if  care  be  exercised.  It  is  wise  to  remember  that,  although  pus  be 
present  in  these  cases,  the  viscidity  may  prevent  its  escape  through  the 
needle,  and  thus  mislead  instead  of  reassure  the  surgeou.  However,  the 
examination  with  a  microscope  of  the  contents  of  the  needle  may  throw 
some  light  on  the  exact  nature  of  the  field  traversed  by  it.  After  removal 
of  the  needle,  the  site  of  the  puncture  is  sealed  with  collodion  or  otherwise 
secured  in  an  aseptic  manner. 

A  trocar  and  cannula  of  small  diameter  can  be  employed  with  the  same 
precautions  as  for  the  needle ;  the  cannula  being  allowed,  if  need  be,  to 
remain  behind  for  two  or  three  days  until  serous  adhesions  have  taken  place, 
when  a  drainage  tube  can  be  substituted  for  it.  Since  the  trocar  is  larger 
than  the  needle,  the  danger  of  injury  of  parts  and  extravasation  of  fluids 
into  the  peritoneal  cavity  is  increased  correspondingly.  The  trocar  is  less 
objectionable  in  those  cases  where  adhesion  of  serous  surface  has  already 
taken  place.  On  the  whole,  the  use  of  the  trocar  and  cannula  can  not  now 
be  regarded  with  as  much  favor  as  formerly. 

The  Operation  by  Direct  Incision. — After  the  location,  by  palpation  or 
the  use  of  the  needle,  of  the  most  direct  site  of  approach  to  the  abscess,  the 
evacuation  can  be  attained  by  an  operation  consisting  either  of  one  or  of 
two  steps,  as  the  case  may  require.  If  hy  one  step.,  make  a  longitudinal 
incision  of  sufficient  length  down  upon  the  abscess  to  reach  the  pus  if  it  be 
above  the  peritonseum,  and  to  the  peritona3um  if  below.  If  the  peritonceum 
he  adherent  to  the  underlying  wall  of  the  abscess,  introduce  through  it  into 


704:  OPERATIVE   SURGERY. 

the  abscess  an  exploring  needle  of  large  size,  followed  by  a  narrow  bistour}-, 
and  finally  by  the  linger,  thus  causing  the  pus  to  escape.  Tf  tJie  peritonceum 
be  not  adherent,  extend  the  primary  incision  to  four  or  five  inches  in  length ; 
arrest  haemorrhage  and  divide  the  peritonteum  to  the  full  extent  of  the 
wound;  draw  the  borders  of  the  wound  apart  with  traction  loops  and  shut 
off  the  peritoneal  cavity  from  the  proposed  site  of  incision  of  the  liver  by  an 
abundance  of  aseptic  gauze ;  introduce  into  the  liver  the  aspirating  needle, 
followed  by  the  bistoury  and  finger  as  in  the  last  instance.  Before  the  pus 
escapes  by  the  side  of  the  finger,  the  borders  of  the  wound  are  pressed 
against  the  liver  to  shorten  the  route  and  facilitate  a  safer  exit.  Finally, 
draw  the  liver  upward  with  the  finger  inserted  into  the  abscess  cavity ;  in- 
crease the  size  of  the  opening  with  the  bistoury ;  catch  the  incised  borders 
of  the  liver  with  forceps,  and  evert  and  hold  them  carefully  in  place ;  sponge 
out  the  abscess  cautiously,  and  examine  the  walls  with  the  finger  for  other 
collections  of  pus.  Arrest  haemorrhage  by  forceps  and  ligature,  or  by  occlu- 
sion of  the  bleeding  points  with  sutures  carried  through  the  border,  plug- 
ging with  sponges  or  gauze.  When  bleeding  is  arrested  cleanse  the  parts ; 
remove  the  original  packing,  and  cleanse  the  peritona3um ;  stitch  the  borders 
of  the  liver  opening  to  those  of  the  abdominal  wound,  introduce  drainage, 
and  dress  antiseptically. 

The  seco?id  step  (Volkmann)  is  practiced  in  the  absence  of  peritoneal 
adhesions  and  with  the  view  of  causing  them  before  opening  the  abscess. 
If  the  condition  of  the  patient  will  warrant  delay  after  the  peritonaeum  is 
exposed,  it  is  divided  and  sewed  to  the  capsule  of  the  liver,  and  the  wound 
is  packed  with  gauze.  The  adhesive  process  can  be  further  stimulated  by 
numerous  needle  punctures  in  the  membrane  before  the  packing  is  intro- 
duced, but,  for  the  purpose  of  securing  adhesion  of  the  serous  surfaces,  it 
is  particularly  necessary  that  they  should  be  pressed  together  by  the  gauze 
packing.  The  abscess  cavity  should  be  carefully  cleansed  by  wiping,  anti- 
septic douching,  etc.,  and  a  very  large  drainage  tube  of  the  proper  length 
introduced  before  the  wound  is  finally  dressed.  Fontan  advises  that  the 
wall  be  curetted  carefully,  and  cites  instances  of  his  own  (forty)  to  prove 
that  this  measure  is  not  only  devoid  of  danger  but  contributes  largely  to  the 
prompt  recovery  of  the  patient. 

In  those  instances  in  which  the  operation  involves  the  chest  wall  resection 
of  part  of  a  rib  or  of  the  costal  borders  (Fig.  1030)  may  be  essential.  It  is 
very  important,  in  instances  of  pleural  involvement  in  these  cases,  to  unite 
the  pleural  surfaces  with  each  other  by  sewing,  if  not  already  adherent,  before 
opening  the  abscess,  otherwise  extensive  and  fatal  pleurisy  may  be  provoked 
by  entrance  to  the  pleural  cavity  of  some  part  of  the  escaping  fluid.  It  is 
sometimes  necessary  in  these  cases  to  pass  through  the  diaphragm  to  reach  the 
pus,  and  pleurisy  will  follow  unless  precautionary  steps  be  taken  (Fig.  1089). 

In  this  operation  make  an  incision  about  three  inches  in  length  paral- 
lel with  the  rib  overlying  the  most  prominent  part  of  the  abscess.  Expose 
and  excise  a  portion  of  the  rib,  carefully  avoiding  the  pleura ;  open  into 
the  pleural  cavity  by  so  dividing  the  subcostal  pleura  as  to  form  a  flap 
intended  to  shut  off  the   serous  cavity,  when    properly  united  with  a  flap 


Ul'EliATlONS   ON    VISCKUA   CUNNKCTEl)   WlJll    I'EUl'J'ON.KUM.     7<J5 

siniilurly  foniicd  from  the  serous  covering  of  the  (Ihiphnigin  at  that  situ- 
ation;  unitt' tightly  the  corresponding  borders  of  the  serous  Hups  with  One 
silk  sutures;  as])irate  the  abscess,  piercing  the  diapliragrn  at  the  point  well 
calcuhited  to  afford  suitable  flaps  for  union  with  the  borders  of  the  tho- 
racic wound  ;  withdraw  from  the  abscess  cavity  a  sufficient  amount  of  pus 
to  relax  its  walls,  thus  obviating  untimely  fhjoding  of  the  wound  with  pus 
when  the  abscess  is  opened  ;  open  through  the  diaphragm  and  unite  the 
borders  of  the  diaphragmatic  wound  with  those  of  the  thoracic,  plugging  if 
need  be  the  former  wound  with  gauze  while  the  sewing  is  being  done  ;  incise 
the  he])atic  tissue  at  the  bottom  of  the  wound,  deepening  it  until  the  abscess 
is  opened  ;  evacuate  the  pus  and  treat  the  abscess  as  in  preceding  instances. 

Tlte  Remarks. — Before  opening  the  abscess  greater  security  is  insured  by 
uniting  the  borders  yet  more  closely  with  a  continuous  catgut  suture. 
Smearing  the  surfaces  of  the  wound  with  iodoformized  vaseline  can  do  no 
harm,  and  it  may  do  much  to  prevent  infection.  If  deemed  advisable  after 
union  of  the  borders  of  the  costal  and  diaphragmatic  pleurae  the  wound  may 
be  plugged  with  gauze  for  four  or  five  days  to  establish  adhesion,  remem- 
bering that  the  consequent  inflammatory  changes  may  obscure  the  subse- 
quent steps  of  the  operation. 

The  Precautions. — Strict  asepsis  and  rigid  enforcement  of  peritoneal 
protection  are  essential  to  a  happy  outcome  in  these  cases.  Exploratory 
aspiration  may  be  followed  by  fatal  leakage,  if  too  large  a  needle  be  used. 
Perforation  of  a  large  vessel  has  arisen  in  this  connection.  Rough  examina- 
tion of  an  abscess  cavity  has  given  rise  to  fatal  bleeding  from  rupture  of  a 
large  vessel,  hence  caution  is  essential  in  this  measure.  In  some  instances 
serous  adhesion  may  not  have  taken  place,  even  in  the  presence  of  evident 
pointing  of  the  tumor. 

The  General  Comments. — A  free  opening  of  the  abscess  should  be  made 
when  the  local  evidences  indicate  the  probability  of  a  more  or  less  prompt 
evacuation  through  rupture  of  its  wall  externally.  Yet  it  is  not  proper  to 
wait  for  these  manifestations,  since  rupture  at  a  less  favorable  situation  may 
happen  without  their  presence  at  all.  When  it  is  determined  that  pus  exists 
in  the  iiver,  its  prompt  removal  is  demanded,  not  only  to  limit  the  further 
destruction  of  liver  tissue  by  extension,  but  also  to  obviate  the  greater  danger 
of  loss  of  life  from  rupture.  Usually  the  local  evidences  of  tumor  are  noted 
in  the  right  hypochondriac  or  epigastric  regions.  In  rarer  instances  less 
marked  evidences  of  lateral  and  posterior  thoracic  involvement  are  observed. 
If  only  constitutional  symptoms  are  present,  the  use  of  the  aspirator  is  ad- 
vised to  detect  the  presence  and  indicate  the  location  of  the  pus  collection, 
the  needle  remaining  as  an  unerring  guide  to  the  pus  w^hen  found.  In  doing 
this  after  the  peritoneum  is  reached,  care  should  be  practiced  to  introduce 
the  needle  at  the  center  of  the  area  of  adhesion,  and  the  caliber  of  the  final 
opening  should,  if  practicable,  be  limited  to  this  area  to  avoid  peritoneal 
infection.  If  the  area  do  not  correspond  to  the  opening  in  the  abdomen,  the 
opening  should  be  shaped  to  conform  to  proper  drainage  requirements.  If 
disconnected  abscesses  be  present  in  the  liver,  one  or  more  may  escape  notice 
even  if  careful  examination  of  the  abscess  cavitv  be  made  with  the  finger, 


ViX;  Ol'KRATIVE   SLIRGERY. 

trocar,  etc.,  after  cvacuution.  Tjittle  can  be  said  in  favor  of  tlie  employment 
of  cautery  or  caustics  for  the  ])roinotion  of  adhesion,  or  of  the  former  for 
opening  the  abscess.  Abdominal  incisions  like  the  thoracic  are  made  over 
the  most  prominent  part  of  the  tumor  about  three  inches  in  leiiij^th  and  in 
the  long  axis  of  the  body.  The  sewing  of  the  tumor  to  the  edges  of  the 
abdomiiud  wound  after  evacuation  of  the  pus,  is  facilitated  by  drawing  the 
organ  forward  with  the  hooked  finger  and  by  passing  all  of  the  sutures  before 
any  are  tied.  After  completion  of  the  hrst  step  of  the  operation  the  intro- 
duction of  two  ligatures  but  a  short  distance  apart  into  the  tissues  at  the 
bottom  of  the  wouiul,  at  the  site  of  the  pro})osed  0})ening,  will  enable  the 
surgeon  to  draw  the  structure  forward  into  the  wound  and  also  will  provide 
a  satisfactory  guide  to  making  the  incision  after  adhesions  are  established. 
The  drainage  tube  should  be  maintained  at  such  a  length  that  impingement 
of  the  eiul  on  the  wall  of  the  abscess  will  not  happen  as  penetration  of  the 
liver  may  follow,  especially  when  the  dressings  are  firmly  ajiplied.  Curetting 
of  the  wall  of  the  abscess,  if  done  at  all  should  be  conducted  with  great  cau- 
tion to  avoid  the  bleeding  incident  to  severance  of  large  vessels.  If  hemor- 
rhage occurs  flushing  of  the  cavity  with  hot  antiseptic  fluids  and  packing 
with  iodoform  gauze  should  be  employed. 

The  Results. — In  the  absence  of  sepsis  or  peritonitis  the  jjatient  usually 
makes  a  prompt  and  satisfactory  recovery.  The  abscess  shrinks  and  finally 
heals  with  cleansing  of  the  cavity,  good  drainage,  and  repeated  dressings. 

The  general  rate  of  mortality  is  about  40  per  cent.  Individual  reports 
give  more  encouraging  results :  as,  48  cases  with  35  recoveries  (Dabney) ; 
47  cases  with  37  recoveries  (Ferron) ;  80  per  cent  of  recoveries  are  reported 
by  Fontan,  which  good  result  he  attributes  to  the  use  of  the  curette.  Mul- 
tiple abscesses — 40  per  cent — are  usually  fatal.  Abscess  of  the  right  lobe 
resulted  fatally  in  50  per  cent,  and  of  the  left  in  43  per  cent  of  the  cases. 

Hydatids  of  the  Liver. — The  liver  is  the  seat  of  hydatid  disease  in  nearly 
sixty  per  cent  of  the  cases  of  hydatid  infliction,  and  when  multiple  the  liver 
is  quite  certain  to  be  involved.  The  plans  of  operative  cure  are  those  directed 
to  the  destruction  of  the  growth  without,  and  with  removal  of  the  contents. 
Addressed  to  the  former  plan  are :  1,  Simple  puncture  ;  2,  puncture  with 
removal  of  a  small  amount  of  the  contents  of  the  sac  ;  3,  puncture  with  medi- 
cation of  the  contents;  4,  electrolysis;  5,  incision;  G,  excision.  Aspiration 
with  removal  of  a  portion  of  the  fluid  is  thought  by  some  to  be  a  compara- 
tively safe  and  efficient  operation,  and  often  quite  as  serviceable  as  the  more 
complicated  and  dangerous  practice  of  introducing  chemical  solutions. 

The  Results. — The  first  and  second  plans  of  practice  are  commended  by 
their  outcome.  A  mortality  of  19  per  cent,  46  per  cent  of  failures  and  54  of 
successes,  is  reported  (Thomas).  Puncture  as  a  means  of  diagnosis  but  not 
of  treatment  is  commended.  The  third  method  gives  a  higher  mortality  rate 
than  do  the  succeeding  ones,  and  therefore  is  not  to  be  employed  except  for 
special  reasons.  Electrolysis  with  simple  puncture  is  no  less  dangerous  than 
the  preceding,  but  much  inferior  to  them  as  a  method  of  cure.  Puncture 
exposes  the  patient  to  the  dangers  of  peritoneal  infection  from  leakage  and 
death  from  haemorrhage  due  to  the  piercing  of  a  large  vessel.     The  securing 


OPERATIONS   ON    VISCKliA    CONXKC'I'KD   WITH    I'Kli  I'I'oN  J-ILIM.     7i)7 

of  aillu'.sioii   bcd'oru   ])iiii(tLiire,  jiccoiii})lislK'cl    by  iiicisioii,  piickiiijf,  etc.,  the 
same  as  in  abscess,  is  a  wise  measure. 

The  Treatment  bij  Incision. — Iiuusion  carried  into  elTect  eitlicu-  in  one  or 
two  stages  in  the  manner  })racticed  for  abscess  of  the  liver  is  the  best  means 
of  treatment.  Ordinarily  the  cyst  can  be  approached  through  an  abdominal 
incision;  sometimes,  however,  the  posterior  thoracic  is  demanded,  depending 
on  the  point  at  which  tlie  cyst  manifests  its  j)resence. 

The  treatment  by  excision  of  the  cyst  wall  and  by  resection  of  a  portion 
of  liver  infested  with  these  cysts  has  been  done  successfully,  but  not  yet 
with  sufHcient  frequency  to  fix  their  comparative  value.  Excision,  while 
iiU'al  in  its  technique,  exposes  the  patient  to  dangers  which  are  not  of  special 
account  in  the  treatment  by  incision. 

Tlie  General  Remarks. — Ilepatotonnj  for  the  cure  of  hydatids  differs  in 
no  essential  part  of  its  technique  from  that  directed  to  the  cure  of  abscess 
of  the  liver.  The  seat,  size,  depth,  and  direction  of  the  incision,  the  pro- 
visions against  peritoneal  infection,  the  establishment  of  drainage,  and  the 
adjustment  of  the  wound  borders,  are  like  the  similar  considerations  in  the 
treatment  of  abscess.  Briefly  stated,  after  a  single  diagnostic  asj^iration, 
viaJce  an  incision  down  upon  the  tumor,  sew  the  borders  of  the  peritonaeum 
to  the  tumor,  remove  the  fluid  portion  of  the  contents  with  the  aspirator, 
make  an  incision  into  the  cyst  an  inch  in  length,  and  sew  the  borders  of 
the  opening  to  the  non-cutaneous  portion  of  the  borders  of  the  abdominal 
wound ;  empty  the  C3'st  with  the  fingers  and  a  spoon,  examine  the  inner 
wall  for  additional  growths  and  for  abscess,  cleanse  the  parts,  drain,  and 
dress  antiseptically. 

The  tension  of  the  cyst  wall  causes  prompt  and  forcible  expulsion  of  the 
contents  as  soon  as  it  is  punctured.  The  toughness  of  the  wall  often  permits 
the  pulling  of  the  cyst  outward,  between  the  ribs  or  elsewhere,  for  safe  drain- 
age, and  even  its  entire  removal  from  the  liver.  Thornton  advocates  primary 
closure  of  the  wound. 

The  Results. — The  general  rate  of  mortality  by  the  direct  methods  varies 
from  fourteen  to  forty-eight  per  cent;  the  former  rate  belonging  to  the  two- 
stage  operation  directed  to  the  primary  attainment  of  adhesions  (Volkmann). 
In  abdominal  approach  the  mortality  rate  is  10.39  per  cent;  in  the  thoracic 
—one  stage — 29.4  per  cent  (Thomas). 

Ilepatectoyny  is  practiced  for  the  removal  of  solid  tumors  of  the  liver  of 
various  kinds.  The  form,  location,  size,  nnmber,  and  nature  of  the  growths 
exercise  a  great  influence  on  the  attempts  and  the  results  of  operation. 
Pedunculated  neoplasms,  those  of  small  size,  single,  and  of  benign  character, 
can  be  removed  successfully  when  accessible  and  superficially  located.  In 
those  of  sessile  form  and  those  more  or  less  completely  hidden  beneath  the 
liver  surface,  free  incision  close  to  the  growth  and  enucleation  are  employed. 
An  isolated  malignant  growth,  and  even  two  or  many  such  growths  when 
small  and  closely  associated,  may  be  removed  singly  by  wide  free  dissection 
and  by  resection  of  the  portion  bearing  them,  esjiecially  when  located  at  the 
margins  of  the  right,  or  in  the  left  lobe  of  the  organ.  The  difficult  part  of 
hepatectomy  relates  primarily  to  the  control  of  haemorrhage  and  the  preven- 


798 


OPERATIVE   SUKOERY. 


tioii  of  air  embolism  ;  seeoiidiirily  to  the  prevention  of  se})sis  and  peritoneal 
complications. 

Pedunculated  tumors  and  such  others  as  may  be  grasped  at  their  l)ases 
by  an  elastic  ligature,  and  even  a  portion  of  the  liver  itself  that  can  be  simi- 
larly treated,  are  attacked  in  one  or  two  stages  and  removed. 

The  Operation  in  One  Stage. — After  thorough  asepsis  and  under  gener- 
ous anesthesia,  make  an  incision  in  the  abdominal  wall  over  the  tumor  from 
the  costal  margin  vertically,  five  or  six  inches  in  length  ;  expose  the  par- 
ietal peritonaeum,  arrest  htemorrhage,  open  the  peritonseum  the  entire  length 
of  the  wound,  bring  upward  into  the  wound  the  portion  of  liver  to  be 
removed,  causing  the  base  to  be  brought  into  close  contact  with  the  margins 
of  the  wound  to  which  it  is  united  by  silk  sutures  passed  through  the  liver 
substance  beyond  the  diseased  area,  thence  through  the  borders  of  the 
abdominal  wound,  and  so  tied  as  to  firmly  unite  the  liver  with  the  abdomen, 
and  causing  the  diseased  i)()rtion  to  appear  witliout;  place  an  elastic  ligature 


\'l 


Fio.  1005. — The  operation  of  lie[)ate('toiiiy. 
Removaf  of  transverse  wedge-shaped  piece 
from  free  border. 


Pio.    lOOG. — 'I'iie   operation   of    hepatec- 
toniy.     Suture  of  wound. 


around  the  base  of  the  protrusion,  allow  it  to  remain  for  three  days,  then 
remove  and  substitute  another.  After  removal  of  the  mass  its  base  heals  by 
granulation. 

The  Remarks. — The  use  of  the  actual  cautery  during  the  later  days  of 
treatment  will  hasten  the  separation  and  lessen  correspondingly  the  putre- 
factive changes  and  the  dangers  of  abscess  and  supptiration  of  the  wound. 
The  elastic  ligature  is  held  in  place  and  guided  by  means  of  long,  curved 
transfixion  pins  passed  transversely  through  the  base  of  the  part  to  be 
removed. 

Tlie  Operation  in  Two  Stages. — In  operation  in  two  stages  the  first  is 
identical  in  its  scope  with  the  preceding,  and  is  supplemented  with  packing 
the  wound  with  gauze  for  five  or  six  days  to  secure  adhesion  between  the 
liver  and  abdominal  wall.  The  second  stage  contemplates  the  removal  by 
dissection  or  cautery  of  the  exposed  portion  of  the  liver,  and  in  the  same 
manner  as  is  practiced  in  the  one-stage  operative  procedures.     As  before 


(Jl'KliA'IMoXS   OX    VISCERA   CONNKC'I'KD   WI'I'II    PHItri'ON .KUM.     79<) 


rcmarkod,  liUMiiorrhiiyo  luul  air  einbolisin  are  iinportiuit  coniplicutions  in  this 
pi-o(«edui(>.  'I'lio  foriiuu-  is  controlled  mid  the  latter  jjrcvented  by  sponge 
pressure  following  closely  the  cutting  agent.  (Jircular  constriction  of  the 
operative  lield  with  a  rubber 
tube ;  application  of  cautery, 
ligature  of  bleeding  points 
with  silk,  the  use  of  the  tam- 
ponade, and  apposition  of 
the  divided  surfaces  with 
sutures,  quilled  (l*'ig.  140)  or 
otherwise,  are  the  common 
means  utilized  to  arrest  bleed- 
ing. In  the  instances  of 
free  incision,  esi)ecially  of  a 
wedge  shape,  ])roinpt  closure 
of  the  wound  with  sutures 
limits  the  loss  of  blood  and 
reduces  the  danger  of  air 
embolism  to  a  minimum. 
In    the    removal    of     deep 

growths  by  dissection,  the  ^^^  loOT.-Tlie  (.i)enition  of  hepatectomy.  Removal 
bleeding   points  are   tied  as  of  a  longitudinal  wedge-shaped  piece, 

soon  as  they  appear,  and  the 

deep  borders  of  the  cavity  are  united  by  buried  catgut  sutures,  the  superfi- 
cial closed  with  fine  sutures,  the  part  is  cleansed,  returned  to  the  abdominal 
cavity,  and  the  abdominal  wound  closed. 

Weclge-sliaped  portions  of  the  organ  can  be  removed  with  antiseptic  pre- 
cautions through  a  free  abdominal  incision  (Figs.  1005,  1006).  Control 
ht\3morrhage  bv  circular  elastic  constriction  ;  make  a  curved  incision  at  either 

side  of  the  base  of  the  tumor, 
so  directed  that  they  meet  each 
other,  especially  at  an  acute 
angle  beyond  the  growth ;  re- 
*  move   the  wedge-shaped    piece 

thus  formed  along  with  the 
morbid  growth  ;  relax  the  con- 
striction, catch  and  tie  the 
bleeding  points  with  silk  as 
fast  as  they  appear  (Figs.  1007, 
1008).  Cleanse  the  wound, 
and  close  it  with  deep  sutures 
introduced  a  third  of  an  inch 
apart  with  a  curved  Hagedorn 
needle. 

Tlie  Precautions. — During  operation  cover  as  carefully  as  possible  the 
divided  surfaces  with  sponge  pressure  to  prevent  air  embolism.  Injury  of 
the  important  vessels  associated  with  the  transverse  fissure,  especially  the 


-f 


-ii5 — 


1 — r 


Fio.  lOON.— T 


ulicration   of   hopatectoniy. 
ture  of  wound. 


Su- 


800  OPERATIVE  SURGERY. 

portal  vein  and  its  large  branches,  shonld  be  ciiutiously  avoided.  Ligature 
of  the  latter  is  liable  to  end  promptly  in  fatal  abdominal  haemorrhage.  The 
free  use  of  cautery  for  the  control  of  bleeding  is  objectionable  because  of  its 
interference  with  subsequent  union.  Caution  must  be  exercised  in  suturing 
the  liver  to  avoid  the  tearing  out  of  the  stitches ;  even  quilled  sutures  and 
stitches  carried  around  strips  of  gauze  may  be  utilized  temporarily  for  the 
purposes  of  better  security.  In  the  instance  of  failure  to  close  a  wound  of 
the  liver  completely  by  sewing,  the  remainder  of  the  wound  is  properly 
treated  by  the  introduction  into  it  of  iodoform  gauze,  which  is  allowed  to 
escape  externally  through  the  abdominal  wound. 

The  Remarks. — In  those  instances  in  which  excision  by  cautery  is  made, 
the  Paquelin  cautery  knife  is  especially  serviceable.  Surgeons  have  repeat- 
edly removed  portions  of  the  liver  as  well  as  tumors  from  its  structure  with 
comparative  safety. 

A  large  portion  of  liver  can  be  removed  without  material  injury  to  the 
patient;  in  fact,  a  third  has  been  removed  in  the  lower  animals  without  a 
fatal  result.  Portions  removed  are  speedily  replaced  apparently  by  increase 
in  the  size  of  already  existing  elements,  and  the  functions  are  promptly 
restored.  Searing  the  cut  surface  with  cautery  prevents  the  escape  of  bile 
from  the  open  ends  of  the  small  ducts,  and  thereby  prevents  its  admission  to 
the  abdominal  cavity  or  external  wound,  as  the  case  may  be.  Temporary 
digital  compression  of  the  pedicle  of  a  growth  or  of  the  liver  substance  con- 
tiguous thereto  will  limit  the  flow  of  blood,  and  increased  advantage  in  the 
application  of  pressure  may  be  gained  by  passing  the  finger  through  the  fora- 
men of  Winslow.  The  slow  tightening  of  broad,  interlocking  silk  sutures 
passed  about  a  third  of  an  inch  apart  through  the  liver  outside  of  a  proposed 
line  of  division  will  admirably  control  hemorrhage.  An  omental  patch,  held 
in  place  by  pressure  and  stitching,  may  soon  establish  an  organized  barrier 
to  the  escape  of  blood  from  the  incised  surface. 

The  Besnlfs. — Twenty-one  cases  are  reported  with  two  deaths. 

Wounds  of  the  Liver. — -Wounds  of  the  liver  arise  from  various  kinds  of 
violence,  especially  from  blunt  and  that  dependent  on  falls,  etc.  The  pecu- 
liarity of  the  normal  liver  structure,  and  its  modification  by  various  forms  of 
structural  disease,  contribute  not  a  little  to  the  liability  of  hepatic  injury. 
The  right  lobe  is  injured  about  four  times  oftener  than  the  left  and  three 
times  more  frequently  than  the  median  portion.  In  injuries  of  the  liver,  the 
characteristic  freedom  and  persistency  of  the  bleeding,  and  the  presence  of 
bile  in  the  peritouc^um,  suggest  the  need  of  prompt  operation.  Strict  asepsis 
should  always  be  employed.  The  abdominal  incision  should  be  free  and  so 
located  as  to  best  expose  the  seat  of  the  injury.  The  median  incision  only, 
or  supplemented  by  another  at  the  right  or  left,  will  commonly  meet  the 
indications.  However,  when  located  high  up  and  well  to  the  right,  an  ob- 
lique incision  along  the  costal  border,  aided  perhaps  by  excision  of  a  part  of 
one  or  more  of  the  ribs,  may  be  advisable.  Collections  of  blood  in  the  peri- 
toneal cavity  often  indicate  the  seat  of  the  injury,  and  their  removal  may 
furnish  the  evidence  of  continuous  bleeding.  The  indicntions  for  treatment 
relate  to  the  arrest  of  hcBmorrhage,  repair  of  the  wound,  cleansing  of  the 


(»i'i;i:ati()Ns  on  visckka  connectkd  wnii  rKin'i'oNMir.M.    sol 


Fi(i.  100!). — Sewing  rupture  of  liver  with  Emmet's  needle. 


peritoniL'iini,  luul  Lhc  cstulilishnn'iit  of  the  lU'cressary  driiiiiuge.  lla'iiiorrhage 
is  tem})orarily  controlled  by  {)uckiii<f  tlio  woiiiui  with  gauze  or  sponges, 
Jiideil  [)erhaps  by  digital  or  clastic  pressure  of  tlio  in  jiircd  part  of  the  oigaii. 
The  ligature  of  the 
bleeding  {)oints  with 
silk,  and  closure  of  the 
won  ml  by  deeply  and 
closely  placed  silk  su- 
tures are  the  ideal 
steps  of  permanent  ar- 
rest of  bleeding  aiul 
final  repair  of  the 
wound  (Figs.  1009, 
1010).  Small  rup- 
tures of  the  surface 
are  closed  quite  well 
by  means  of  purse- 
string  sutures  (Fig. 
816).  In  the  event 
of  incomplete  or  non- 
closure of  a  wound  for 
any  reason,  a  tamponade  of  iodoform  gauze  should  be  introduced  for  a  day 
or  two,  as  the  case  may  be,  depending  on  the  presence  and  character  of  the 
bleeding.  The  use  of  cautery  in  wounds  of  the  liver  is  objectionable  since 
it  interferes  with  the  processes  of  repair,  and  invites  tlie  occurrence  of  sec- 
ondary hcemorrhage.  Tampons  of  sterilized  gauze  are  much  prompter  and 
securer  agents  of  arrest  than  cautery.  In  gunshot  and  stab  wounds  the 
hiemorrhage  is  arrested  by  tampon  and  such  open  vessels  closed  with  silk 

as  may  be  found  practicable.  The 
tampons  are  removed  every  two  or 
three  days  with  caution,  and  fresh 
and  smaller  ones  introduced  to 
facilitate  drainage.  The  abdomi- 
nal wound  should  not  be  com- 
jiletely  closed  so  long  as  a  danger 
of  haemorrhage  or  infection  is 
present.  The  removal  of  blood 
clots  and  free  blood  from  the 
peritoneal  cavity  should  be  car- 
ried into  effect,  and  good  drainage 
established  when  suggested  by  the 
possibility  of  the  occurrence  of 
infection. 

It  is  w^orthy  of  note,  how- 
ever, that  the  presence  of  blood  in  the  peritoneal  cavity  is  objectionable 
in  proportion  to  the  degree  of  infection  that  may  be  associated  with  the 
injury. 


Fig.  1010. — Sewing  liver,  sutures  placed  for 

tying- 


302  OPERATIVE   SURGERY. 

The  Restilts. — In  rupture  prompt  operative  action  appears  to  increase 
the  rate  of  recovery  from  15  per  cent  to  45,  iu  gunshot  wounds  from  55  per 
cent  to  70,  and  in  stab  wounds  from  64  per  cent  to  quite  75. 

Hepatopexy. — Hopatopexy  relates  to  the  cure  of  abnormal  mobility  of 
part  or  the  entire  liver  by  fixation  of  tlie  organ  to  the  abdominal  wall.  The 
requisite  incision  for  fixation  is  made  over  the  prolapsed  part  of  the  liver 
parallel  with  the  costal  border,  the  liver  is  reduced  to  the  normal  position 
and  retained  by  means  of  several  stout  silk  sutures  connecting  it  with  the 
j)osterior  surface  of  the  abdominal  wall.  The  patient  is  required  to  lie  still 
for  several  weeks  in  order  to  secure  as  firm  union  as  possible. 

Ramsy  fastened  a  prolapsed  liver  in  place  successfully  by  means  of  strong 
silk  ligatures  passed  through  the  round  ligament  and  over  the  cartilage  of 
the  seventh  rib  and  tied,  aided  by  a  kangaroo  tendon  connecting  the  extreme 
right  lobe  of  the  liver  with  the  abdominal  wall  corresponding  to  that  point. 
Treves  and  others  have  recorded  apparently  successful  issues  from  the 
measure. 

The  Results. — The  results  of  the  several  cases  thus  far  noted  seem  to 
justify  the  course  pursued,  and  encourages  a  belief  in  further  efforts  to 
remedy  the  ill  effects  in  Glenard's  disease. 

Hepatostomy  (Cholangiostomie). — Hepatostomy  consists  in  the  establish- 
ment of  a  fistulous  communication  between  one  or  more  extra-hepatic  bile 
ducts  and  the  surface  of  the  body  to  relieve  the  ducts  of  accumulated  bile 
due  to  obstruction  from  biliary  calculi.  An  abdominal  incision  is  made  over 
the  portion  of  the  liver  harboring  the  distended  ducts,  and  after  careful  iso- 
lation of  the  field  of  operation  an  incision  is  made  into  the  liver  and  deep- 
ened until  the  dilated  duct  is  reached.  Careful  cleansing  of  the  wound  and 
renewed  packing  of  the  field  is  done  before  the  duct  is  opened,  to  avoid  the 
possibility  of  infection  from  the  escape  of  its  contents.  The  duct  is  then 
opened,  the  wound  carefully  cleansed,  and  the  gallstones  are  removed.  The 
presence  of  other  dilated  ducts  are  sought  for  and  relieved  in  a  similar  man- 
ner as  the  preceding.  The  wound  is  again  carefully  cleansed,  the  borders 
of  the  hepatic  and  gall-duct  incisions  are  united  to  those  of  the  abdominal 
wound  by  sewing,  and  the  remaining  portions  of  the  latter  wound  are  closed 
with  sutures,  leaving  the  fistulous  opening  to  heal. 

The  Results.  —  Thornton  operated  successfully  upon  a  patient  by  this 
method  of  practice. 

The  Operation  for  the  Cure  of  Ascites  from  Cirrhosis  of  the  Liver. — In 
1896  Drwnmond  and  Morison  called  attention  to  an  operative  procedure 
practiced  in  two  instances  by  the  latter  for  the  relief  of  ascites  due  to  cirrho- 
sis of  the  liver. 

Morison  opened  the  abdomen  in  the  median  line  between  the  umbilicus 
and  the  pubis,  removed  the  fluid  by  sponging,  scrubbed  the  anterior  parietal 
peritonasum,  also  the  visceral  layers  of  the  spleen  and  liver  and  the  parietal 
portions  corresponding  with  them.  He  then  united  with  sutures  succes- 
sively the  scrubbed  surfaces  of  the  spleen  and  the  liver,  and  the  anterior  sur- 
face of  the  great  omentum  with  the  corresponding  scrubbed  surfaces  of  the 
parietal  peritoneeum.     The  abdominal  wound  was  then  closed  except  at  the 


Ol'KirvriDN'S   ON    VMSCKIIA    CONNKCTKI)    WI'I'II    I'lllH'I'OX JOUM.     803 


lower  ciul,  throiii,'li  whicli  :i  ^'luss  tiilx'  was  passed  into  Douglas's  pouch. 
The  ubdoineii  was  then  supptM-teil  lirrnly  by  several  adhesive  strips  passed 
around  it,  thus  maintaining  tiie  apposed  surfaces  in  suitable  contact  for  final 
adhesion.  Later  Weir  practiced  the  plan  for  a  sitnihir  purpose  and  substan- 
tially in  a  like  manner.  liroicn,  of  New  York,  reports  a  recent  and  success- 
ful case. 

The  Jii'sulfs. — Fourteen  cases  are  reported,  7  of  which  aj)i)ear  to  have 
been  materially  benefited  or  cured  by  the  operation  (Brown),  and  3  died 
from  the  operation.  The  many  instances  of  practical  cure  following  tapping 
and  the  uncertainty  of  the  exact  patiiological  state  of  the  liver,  together 
with  the  somewhat  formi- 
dable character  of  the  opera- 
tion and  the  liability  of  in- 
fection, invest  the  operation 
at  present  with  a  large  ele- 
ment of  doubtful  expedi- 
ency. 

Operations  on  the  Gall 
Bladder. — The  gall  bladdei- 
is  fre(|uently  operated  on  for 
the  removal  of  gallstones, 
purulent  collections,  etc. 

77ie  AiKtfnniical  Points. 
— The  normal  gall  bladder 
is  from  two  and  a  half  to 
five  inches  in  length,  an 
inch  and  a  half  across  at 
the  widest  point,  holds 
about  an  ounce,  and  con- 
tains calculi  in  about  ten 
per  cent  of  the  adult  sub- 
jects. When  filled,  the 
fundus  extends  beyond  the 
border  of  the  liver  at  a  point 
corresponding  to  the  carti- 
lage of  the  ninth  or  tenth 
rib,  more  frequently  the 
former.  The  upper  surface 
lies  in  contact  with  and  is  pio.  1011 
attached  to  the  liver  by  con- 
nective tissue,  while  the  un- 
der   surface   and    the   sides 

are  covered  with  peritonaeum  (Fig.  1U14).  Brewer  reports  the  presence  of  a 
distinct  mesentery  in  four  per  cent  of  a  hundred  dissections  made  by  himself 
and  in  these  instances,  frequently  supplemented  by  an  outward  extension  of 
the  lesser  omentum,  thus  forming  a  double  mesenteric  arrangement.  The 
late  Greig  Smith  reported  somewhat  similar  findings.  The  under  surface 
57 


The  biliary  vessels  and  gall  bladder,  a. 
Cystic  duet.  b.  Bile  duet.  c.  Hepatic  duct.  (/. 
Common  duct.  e.  Duodenal  orifice.  /.  Duct  of 
Wirsunjjr. 


804 


OPERATIVE   SURGERY. 


lies  in  close  connection  with  the  first  part  of  the  diiodenum  and  tlie  hepatic 
flexure  of  the  colon.  The  cystic  duct  is  about  an  inch  and  a  half  to  two  inches 
long,  and  lined  with  mucous  membrane  so  arranged  in  a  spiral  manner  around 
the  lumen  as  to  narrow  the  caliber,  rarely  permitting  the  introduction  of  a 
probe,  and  resisting  the  removal  of  calculi  (Fig.  1012).  This  duct  runs  down- 
ward to  the  left  in  the  lesser  omentum,  having  the  hepatic  artery  on  its  left  and 

the  portal  vein  behind  it,  and  joins  the  hepatic 
duct  at  an  acute  angle  (Fig.  1013).  The  hepatic 
duct  is  about  two  inches  long  and  arises  by  two 
branches,  one  each  from  the  right  and  left 
lobes  of  the  liver,  and  runs  downward  and  to 
the  left  in  the  lesser  omentum  with  the  he- 
patic artery  at  the  left  side.  The  common 
duct  varies  in  length  from  an  inch  and  a  half 
to  about  five  inches,  having  an  average  length 
of  about  three  inches,  is  formed  by  the  cystic 
and  hepatic  ducts,  and  passes  at  first  between 
the  layers  of  the  lesser  omentum  in  front  of 
the  portal  vein,  to  the  right  of  the  hepatic 
artery,  and  behind  the  first  part  of  the  duode- 
num (Fig.  1014) ;  it  then  j^asses  between  the 
second  part  of  this  intestine  and  the  head  of 
the  pancreas  and  ends  by  entering  obliquely 
into  the  lower  part  of  the  second  portion  of 
the  duodenum,  lying  in  the  walls  of  the  gut 
for  three  fourths  of  an  inch  before  its  termi- 
nation, which  is  marked  by  a  small  mucous 
papilla  located  about  three  and  a  half  to  four 
inches  from  the  pylorus.  Brewer  points  out 
the  fact  that  the  papilla  (Fig.  1012)  can  be 
located  quite  well  in  the  living  subject  by 
passing  the  left  index  finger  through  an  open- 
ing made  into  the  second  portion  of  the  gut, 
downward,  inward,  and  backward  to  a  point 
about  an  inch  and  a  half  below  the  crescentic 
fold  of  mucous  membrane  located  at  the  flex- 
ure indicating  the  junction  of  the  first  two 
portions  of  the  duodenum,  the  fold  resting 
opposite  the  middle  of  the  second  phalanx, 
and  its  presence  being  "  markedly  accentuated 
by  upward  traction  of  the  edges  of  the  wound."  The  general  diameter  of 
the  common  duct  is  two  lines ;  below  its  junction  with  the  pancreatic  it  is 
three  lines.     The  smallest  diameter  is  at  the  entrance  of  the  duodenum. 

The  tapping  with  a  trocar  and  cannula  and  the  aspiration  of  a  dis- 
tended gall  bladder  are  by  no  means  trivial  matters.  Not  infrequently  a 
resulting  leakage  has  been  followed  by  fatal  peritonitis  and  death.  Neither 
of  these  measures  can  be  regarded  as  wise  for  the  purposes  of  diagnosis. 


Fk;.  1012.— The  gall  bladder  and 
hiliarv  ducts,  a.  Cavity  of  the 
gall  bhidder.  h.  Neck  of  the 
gall  bladder,     c.  Cystic  duct. 

d.  Spiral  valve  of  cystic  duct. 

e.  Common  hepatic  duct.  /. 
Common  bile  duct.  g.  Pan- 
creatic duct.  h.  Ampulla  of 
Vater.  i.  Second  portion  of 
duodenum,    j.  Biliary  papilla. 


OPEI{ATIOXS   OX    VISf'KltA   ('(JNNECTED    WITH    F'ERITON^UM.     805 


as  they  are  less  safe  as  jn-iniary  measures  than  is  an  explorative  incision.  The 
hitter  wiien  properly  conducted  is  devoid  of  special  danger,  and  therefore 
may  constitute  wisely  the  primary 
step  of  complete  o])eralive  relief. 
The  tap[)ing  or  aspiration  of  an  ex- 
posed and  thoroughly  isolated  gall 
hladder  for  the  puri)o.se  of  diagnosis 
or  relief  from  overdistention  is  pru- 
dent and  justifiable  practice. 

The  introduction  through  the  ab- 
dominal wall  into  the  gall  bladder 
of  a  long,  slender  needle,  either  in- 
dependently or  combined  with  tro- 
car and  cannula,  for  the  purpose  of 
determining  the  presence  of  calculi, 

is  dangerous,  and  made  uniustifiable    v'm    imo     t?„i„+;       *S         ^     ^       lui 

o       ^    '  J  riG.   1U1.:>. —  Itelation  of  vessels  at  and  below 

by  the   efficacy  of  explorative    inci-         the  transverse  fissure,     a.  Gall  bladder,     b. 

sion  with  strict  asepsis  and  localized        ^'j^^l^^  ''"f/    «.  Common  duct    d.  Hepatic 
,      .  ^  duct.     e.  Hepatic  arterv.    /.  Hepatic  vein, 

anaesthesia. 

Cholecystotomy.— Cholecystotomy  is  a  term  applied  to  the  operation  of 
opening  the  gall  bladder  for  the  purpose  of  removal  of  the  contents.  The 
operation  may  be  completed  at  one  or  two  stages  and,  in  the  first  instance, 

the  contents  of  the  tumor  mav 
be  evacuated  before  or  after  sew- 
ing the  walls  of  the  tumor  to 
the  borders  of  the  abdominal 
wound. 

27^6  Operation  (primary  in- 
cision and  secondary  fixation 
of  the  gall  bladder  to  the  ab- 
dominal wall). — After  the  neces- 
sary aseptic  precautions,  Avitli 
the  patient  lying  on  the  back, 
locate  the  cartilage  of  the  tenth 
rib  and  make  an  incision  from 
it  downward  and  forward  in  the 
course  of  the  fibers  of  the  ex- 
ternal oblique  muscle  for  three 
or  four  inches ;  separate  and 
draw  apart  the  fibers  of  this 
muscle  and  those  of  the  succeed- 
ing muscles  as  they  appear  {Greig 

p       ,.,,.      .     ^      .    ,      ,    .  ,  ,  Smith);    pinch    up    and    divide 

JfiG.    1014. — Anatomical  relations  at   the  under  ^,  .,  .  ,  ^i 

surface  of  the   liver,     a.  a.   Portal  vein.     b.  the  peritonjt^um  ;    introduce  the 

Common  duct.    c.  Cystic  duct.    cl.  Hepatic  index    finger   to    the   abdominal 
duct.     e.    Hepatic    arterv.      f.   Hepatico-duo-  ..  -T         -,         ,,  n  ,  ,    •, 

denal   ligamont-i.   e.,   right   border   of   the  ^^^^^^y  ''^^^  explore  the  gall  blad- 

lesser  omentum.  der  if  it  be  not  too   much  dis- 


806 


OPERATIVE  SURGERY. 


^r^'i 


Fig.  1015.— Instruments  employed  in  operations  on  the  gall  bladder  and  gall  ducts. 

,  Curved  and  straight  scissors,  b.  Needle  holder,  c.  Stone  forceps,  d.  Forceps  for 
crushing,  with  rubber-protected  jaws.  e.  /,  g,  h.  Forceps  for  catching  calculi. 
i.  Long  silver  probe,  j.  Scoop.  /*;.  Hvpoderinic  syringe  and  mouse-tooth  forceps. 
I.  Chromicized  catgut,  m.  Halsted's  hammer  (assorted  sizes),  n.  Sponge  holder. 
0.  Costotome.  p.  Blunt  hook,  tenaculum,  and  blunt  retractor,  q.  Spatula,  r.  Hal- 
sted's curved  needles,  s.  Curved  needles  for  sewing  and  straight  for  breaking  cal- 
culi.    Scalpels,  bistouries,  forcipressure,  ligatures,  anchored  wipers,  etc.,  are  needed. 


OI'KIIATIONS   ON    VISCEIiA   CONNl^^C'TKI)    WI'IMI    l'KI!lT()\yKl'M.      807 

toiidtnl  for  this  |)urp()sc  ;  if  iioii-iulhereiit  puck  the  l)ordors  of  the  exposed 
part  of  the  hhukler  with  gauze  or  sponges,  introduce  a  small  trocar  or  fine 
aspirating  needle  at  tiie  lowest  point  of  the  exposed  part,  and  as  the  contents 
escape  seize  the  relaxing  walls  of  tiie  bladder  above  and  below  the  point  of 
puncture  with  fine  forceps  and  draw  the  bladder  cautiously  into  the  abdomi- 
nal wound  and  even  through  it,  if  the  conditions  will  permit.  When  the 
fluid  is  renu)ved,  place  a  broad  sponge  around  the  exposed  part  and  make  a 
vertical  incision  with  scissors  into  the  bladder  of  suflicient  size  to  admit  the 
finger ;  grasp  the  sides  of  the  incision  close  to  the  border  with  forceps,  or 
control  them  by  means  of  traction  loops ;  draw  the  bladder  still  farther  for- 
ward and  give  the  forceps  or  loops  in  charge  of  an  assistant;  arrest  haem- 
orrhage; introduce  the  index  finger  into  the  cavity  of  the  bladder  and  note 
its  contents;  remove  small  stones  with  a  scoop,  larger  ones  with  forceps, 
and  liberate  impacted  ones  with  the  finger  or  scoop,  combined  with  external 
manipulation,  being  careful  not  to  tear  or  bruise  the  walls  of  the  gall  bladder 
and  cystic  duct.  Stones  immovably  fixed  in  the  cystic  duct  require  a  special 
technique  for  removal  (page  813).  Having  removed  the  stones,  thoroughly 
cleanse  the  parts,  including  the  cavity  of  the  gall  bladder,  with  aseptic  fiuid ; 
remove  tlie  sponges,  noting  that  all  are  accounted  for;  push  aside  the  intes- 
tines and  begin  a  systematic  examination  of  the  cystic,  common,  and  hepatic 
ducts  to  ascertain  the  presence  of  movable  or  impacted  calculi ;  cleanse  the 
peritoneum  and  suture  the  borders  of  the  wound  in  the  gall  bladder  by  con- 
tinuous or  interrupted  stitches  to  those  of  the  abdominal  wound,  omitting  the 
skin ;  pass,  when  feasible,  all  of  the  sutnres  before  tying  any.  Introduce  a 
rubber  drainage  tube  up  to  the  cystic  duct  that  it  may  better  convey  away  the 
bile,  or  close  the  opening  in  the  bladder  around  the  tube  with  a  purse-string 
stitch  for  the  same  purpose ;  apply  to  the  wound  iodoform  gauze  and  around 
the  tube  the  ordinary  aseptic  variety,  which  is  changed  as  circumstances  re- 
quire. The  sutures  are  removed  at  the  end  of  a  week,  the  drainage  tube  be- 
ing kept  in  place  longer  if  need  be.  The  resulting  biliary  fistula  will  soon 
close  if  the  common  duct  be  pervious;  if  not, a  permanent  fistula  will  follow 
which  requires  special  treatment  for  cure  (page  823).  If  the  gall  bladder  be 
too  much  shrunken  to  permit  of  its  union  with  the  borders  of  the  wound  in 
the  manner  Just  described,  the  peritonaeum  should  be  separated  and  turned 
upward  and  sewed  to  the  shriveled  edges  of  the  bladder.  Rohson  advises  that 
the  great  omentum  be  raised  up  and  utilized  for  the  purpose."  Murphy  has 
modified  his  button  for  the  purpose,  and  in  writing  of  the  matter,  he  says : 
"  It  can  be  easily  and  rapidly  inserted  deep  in  the  abdominal  cavity,  though 
the  gall  bladder  may  be  very  much  contracted ;  it  also  prevents  with  cer- 
tainty the  contact  of  the  gall-bladder  contents  with  the  abdominal  viscera 
until  such  time  as  adhesions  have  formed  around  the  tube ;  and  finally  it 
leaves  a  large  opening  when  the  instrument  is  withdrawn  from  the  gall  blad- 
der, through  \vhich  calculi  may  be  extracted." 

The  ojjeration  with  the  hitton  tube  is  performed  as  follows :  An  incision 
is  made  in  the  abdominal  wall,  beginning  at  the  ninth  costal  cartilage,  parallel 
to  the  external  border  of  the  rectus  muscle  for  a  distance  of  two  and  one-half 
inches.     The  gall  bladder  is  located,  a  sufficient  surface  of  its  wall  exposed, 


808 


OPERATIVE   SURGERY. 


the  contents  are  aspirated,  the  purse-string  suture  is  introduced,  the  fjall  bhid- 
der  incised,  tlie  male  half  of  the  button  inserted,  and  the  {)ui-se  string  tied 
and  cut  short ;  the  tubular  portion  of  the  button  is  then  pressed  into  position, 
the  tube  drawn  out  as  far  as  the  gall  bladder  will  permit,  and  held  there 
with  a  pin  passed  through  the  openings  in  the  side  (Fig.  lOI(J).  The  isola- 
tion of  a  large  drainage  tube  introduced  into  the  blad- 
der, with  carefull}^  arranged  iodoform-gauze  packing, 
will  soon  establish  a  new  and  adventitious  conduit  for 
the  escape  of  bile. 

Tlie  Preccmtiotis. — Soiling  of  the  peritonieum  with 
the  fluids,  and  the  loss  of  sponges  in  the  abdominal 
cavity,  must  be  carefully  prevented.  Bruising  of  the 
gall  bladder  by  manipulation  or  forcipressure  should 
be  avoided,  since  sloughing  may  be  the  result.  The 
gall  bladder  should  be  seized  in  the  line  of  its  pro- 
posed division,  so  that  pinched  tissue  will  lead  to  no 
significant  harm.  The  aspirating  needle  should  be  in- 
serted as  low  down  as  possible,  so  that  the  puncture 
will  not  be  obscured  by  retraction  of  the  gall  bladder 
with  the  escape  of  the  fluid.  The  common  duct  should 
be  examined  carefully  for  permanent  obstruction  before 
the  gall  bladder  is  sewed  to  the  abdominal  wound,  and 
if  thus  obstructed  cholecystenterostomy  should  be  per- 
formed. At  this  time  the  portion  of  intestine  corre- 
sponding to  the  end  of  the  duct  should  receive  careful 
manipulative  investigation,  as  a  small  stone  or  an  insig- 
nificantly small  morbid  growth  there  may  impede  the 
escape  of  bile.  The  writer  has  met  with  a  case  of  the 
latter  kind.  The  biliary  fistula  will  close  much  quicker 
if  the  integument  be  omitted  in  joining  the  abdominal 
wound  with  the  gall  bladder.  If  obstruction  of  the  common  duct  have  escaped 
the  attention  of  the  surgeon  at  the  time  of  operation,  the  fistula  resulting 
from  its  presence  can  be  cured  only  by  removal  of  the  stones.  For  this  pur- 
pose a  probe  can  be  carefully  used  to  push  the  stone  along.  The  injection 
of  fluids  to  dissolve  the  stone  is  exploited,  but  it  can  not  be  regarded  with 
favor.  The  practice  of  closure  of  the  gall  bladder  and  its  return  to  the 
abdominal  cavity,  with  immediate  closure  of  the  abdominal  wound  (chole- 
cystendysis),  should  be  practiced  with  discretion.  The  temporary  advan- 
tages gained  by  this  course  do  not  always,  in  our  judgment,  otfset  the  dan- 
gers that  may  follow  it. 

The  Remarks. — If  the  bladder  be  not  much  distended,  aspiration  can  be 
omitted  and  a  free  incision  made  at  once,  the  fluid  being  caught  by  sponges 
or  conducted  away  by  a  small  trough  of  rubber  tissue,  oiled  silk,  etc.  The 
direction  of  the  abdominal  incision  is  varied  according  to  the  predilection  of 
the  operator,  the  needs  for  observation  and  manipulation  of  the  organs,  and 
the  preservation  of  the  abdominal  nerves.  Keen  advises  that  it  be  made 
parallel  with  the  cartilaginous  borders  of  the  ribs;   fzer^^  recommends  a 


Fig.  101(5.— Murphy's 
modified  button  for 
drainage  in  cliole- 
cystotomy. 


()iM:i:A'ri()NS  on  viscioka  connkctki)  wi'iii  I'l'iin'roxjii'M.    ^09 

ri,f,'ht-iUi<;lo(l  incision,  so  ))liu-(Ml  tluit  the  fiiiHliis  of  the  l)l;i(ldcr  sli;ill  lie  be- 
tween the  viTticul  and  hori/ontal  j)arts  of  the  cut.  The  "  {^M'idiron  "  dissec- 
tion of  (Jreig  Stnitli  is  often  of  ample  dimension,  and,  like  the  others,  can  be 
extended  to  meet  the  requirements  by  division  of  the  muscular  fibers,  ffoing 
even  into  the  rectus  abdominis  if  need  be.  In  tiiis  plan  the  natural  tendency 
of  the  separated  libers  to  come  together  prevents  undue  subsequent  weaken- 
ing of  the  abdominal  wall  at  the  seat  of  operation.  A  vertical  incision  in 
the  linea  semilunaris  is  convenient  for  explorative  purposes.  It  may  be 
necessary  to  break  up  connecting  adhesions  before  the  bladder  can  be 
brought  into  the  wound  sutliciently  to  pi'event  ])critoneal  infection.  If  the 
gall  bladder  be  ailherent  to  the  abdominal  wall  already  (one  stage),  or  be 
sewed  to  it  before  evacuation  (two  stages)  of  the  tumor  (primary  fixation 
and  secondary  incision),  there  is  less  ilanger  of  peritoneal  infection,  but  the 
operation  is  necessarily  less  complete  because  of  the  inability  to  examine  the 
outlying  ducts  for  the  presence  of  calculi.  However,  in  all  other  resj)ects  the 
techni(jue  is  similar  to  the  method  by  primary  incision  and  secondary  fixa- 
tion of  the  gall  bladder.  Cholecystotomy  and  the  removal  of  the  cause  de- 
manding the  operation  implies  much  indeed,  and  sometimes  more  than  can 
be  attained.  Therefore,  the  surgeon  should  be  prepared  to  meet  the  de- 
mands of  every  phase  of  the  case  in  an  operative  sense,  and  likewise  to  be 
reconciled  to  complete  failure  in  a  philosophical  one. 

Tlie  Eesults. — The  death  rate  in  the  absence  of  cholffimia  is  about  5 
per  cent,  and  even  less  in  some  instances.  With  protracted  chohemia  the 
rate  is  increased  and  is  chiefly  due  to  the  shock  and  haemorrhage  provoked 
by  the  cholffimic  state.  In  about  a  third  of  the  cases  of  operation  long  stand- 
ing and  persistent,  biliary  fistula?  have  followed,  due,  in  many  cases,  to  faulty 
observation  and  technique.  More  definitely  stated,  in  161  cases  (primary  in- 
cision with  secondary  sewing),  46  cases  of  complete,  48  of  doubtful  cure,  35 
W'ith  fistulous  termination,  and  33  deaths  resulted.  Of  the  last,  15  died 
directly  and  17  indirectly  from  the  operation.  In  30  cases  (primary  sewing 
with  secondary  incision),  11  were  completely  cured,  2  uncured,  4  had  fistulae 
remaining,  and  13  died,  6  directly  and  7  indirectly,  from  the  operation.  In 
GG  cases  (operation  in  two  stages),  42  were  cured,  3  unbenefited,  1  improved, 
4  had  permanent  biliary  and  7  permanent  mucous  fistulas,  1  of  doubtful  out- 
come, and  8  died  (Courvoisier  and  ^lartig).  Individual  experience  (Kehr) 
exhibits  a  much  better  result — i.  e.,  in  96  cases  in  one  stage  and  3  in  two,  all 
recovered,  llohson  reports  115  cases  with  5  deaths;  3  were  the  subjects  of 
cancer  and  2  of  su]ipurative  cholangitis  with  jaundice. 

Cholecystendysis. — Cholecystendysis  consists  in  closing  the  opening  in 
the  gall  bladdei',  returning  it  to  the  abdomen,  and  uniting  the  abdominal 
wound  partially  or  completely  at  one  sitting.  When  this  course  is  contem- 
plated the  ducts  should  be  unobstructed,  the  opening  made  into  the  gall  blad- 
der small  and  near  to  the  fundus,  the  borders  not  lacerated,  and  healthy,  the 
calculi  not  large,  readily  removed  entire  or  in  fragments,  and  without  the 
presence  of  evidences  of  infection  or  peritonitis.  The  reverse  of  these  condi- 
tions contraindicate  the  adoption  of  the  procedure.  The  margins  of  the  in- 
cision and  of  a  rupture  of  the  gall  bladder  should  be  carefully  united,  and 


810  OPERATIVE  SURGERY. 

prefcrabl}'  by  three  rows  of  sutures.  The  first  row,  a  continuous  suture  of 
catgut,  uniting  the  borders  of  the  mucous  membrane ;  the  second  of  fine  in- 
terrupted silk,  joining  together  the  mucous  coats ;  the  third  row  of  a  similar 
kind  as  the  second,  and  uniting  the  serous  layers  after  the  manner  of  Lem- 
bert. 

The  Remarks. — The  plan  (Zielewicz)  of  temporarily  closing  the  cystic 
duct  with  a  catgut  ligature,  so  as  to  permit  union  of  the  line  of  sewing 
before  the  absorption  of  the  ligature  allows  bile  to  enter  the  bladder,  is  open 
to  the  objection  of  failure  because  of  lax  tying,  or  the  causation  of  ulceration 
and  stricture  on  account  of  too  firm  seizure  and  delayed  absorption  of  the 
ligature.  Czernifs  proposition  of  uniting  the  closed  margins  of  the  wound 
in  the  gall  bladder  to  the  peritoneum  of  the  abdominal  wound  and  entire 
closure  of  the  latter  in  the  usual  manner  is  needlessly  unsafe,  as  the  leaving 
open  of  a  small  portion  of  the  abdominal  wound  will  obviate  the  danger  of 
peritoneal  infection  without  materially  delaying  cure.  Whenever  the  borders 
of  the  opening  in  the  gall  bladder  are  torn  or  bruised,  from  ruj^ture  or  ma- 
nipulation, they  should  be  trimmed  before  sewing.  Calculi  of  large  size 
should  be  broken  before  removal,  and  cautiously  extracted  to  avoid  bruising 
of  the  borders  of  the  opening  into  the  gall  bladder. 

The  Results. — In  59  cases  45  recovered  and  9  died,  ;j  directly  and  C  indi- 
rectly, from  the  operation.  Four  of  the  remainder  sustained  recurrence  and 
one  continuous  fistula. 

Cholecystectomy. — Cholecystectomy  is  a  term  applied  to  the  operation  of 
reniuvul  of  the  gall  bladder.  It  is  especially  adapted  to  those  cases  in  which 
the  gall  bladder  is  so  much  shrunken,  thinned,  or  atrophied  as  to  prevent 
sewing  it  to  the  abdominal  wound ;  also  to  those  in  which  the  cystic  duct  is 
closed  by  structural  thickening.  Limited  cancer  of  the  gall  bladder,  exten- 
sive ulceration  or  rupture,  overdistention,  with  complete  closure  of  the  duct 
and  the  presence  of  a  persistent  mucous  fistula,  also  are  indications  for  the 
operation.  It  is  proper  to  say,  however,  that  the  removal  of  the  gall  bladder 
presupposes  that  no  gallstones  are  iiresent  in  the  biliary  tract,  and  empha- 
sizes the  hope  that  none  will  appear  thereafter,  since  it  eliminates  one  avenue 
of  lodgment  and  escape,  and  proportionately  measures  the  gravity  of  their 
presence.  • 

The  Operation. — Expose  the  gall  bladder  as  for  cholecystotomy ;  isolate 
the  organ  from  the  peritoneal  cavity  with  abundant  sponge  and  gauze  pack- 
ing ;  turn  up  the  border  of  the  liver ;  make  two  parallel  incisions,  one  at 
either  side  of  the  gall  bladder,  through  the  restraining  peritoneum  (Fig. 
1014) ;  separate  the  gall  bladder  from  the  liver  from  the  fundus  upward  to 
the  cystic  duct;  divide  the  duct  between  two  ligatures;  asepticize  the  prox- 
imal end  with  cautery ;  unite  the  peritoneal  flaps  with  stitches ;  close  the 
abdominal  wound  promptly  and  completely  when  thorough  asepsis  is  assured, 
or  introduce  a  small  drainage  tube  leading  to  the  seat  of  the  operation, 
especially  to  the  end  of  the  duct,  if  thought  wise. 

The  Remarks. — Sometimes  adhesions  and  haemorrhage  complicate  the 
operation,  requiring  the  use  of  forcipressure,  ligatures,  etc.,  and  extension  of 
the  abdominal  incision  for  a  better  view  and  manipulation.     Cholemia  pre- 


OPHUATIONS  ON    VISCKHA   CONNECTED    WITH    I'HRITON.KUM.     811 


disposes  stroii,i,'ly  to  liii'morrlui^c,  and,  when  trouble  is  aiiti(U[)iite(l,  packing  of 
the  wound  shouUl  be  practiced  for  two  or  three  days  before  complete  closure 
is  made.  A/ai/o  advises  removal  only  of  th(!  niucous  membrane  and  cites  sev- 
eral favorable  results.     Senn  doubts  the  expediency  of  the  practice. 

71tf  Ikcsulffi. — The  general  deatii  rate  is  al)out  17.25  per  cent,  of  which 
3  per  cent  are  ihie  to  individual  causes,  liohsoit  reports  the  rate  at  14.28 
per  cent. 

Cholecyslenterostomy. — Cholecystenterostomy  is  the  establishment  of  a 
biliary  fistula  between  the  gall  bladder  and  the  intestine,  usually  the  duode- 
num, for  the  relief  of  chohwmia  incident  to  complete  division,  ulcerative 
perforation, and  irremediable  obstruction  of  the  common  duct.  It  is  advised 
also  in  chronic  cholecystitis  in  some  cases  and  for  obstruction  of  the  cystic 
duct  when  removal  of  the  gall  l)ladder  is  not  feasible,  persistent  fistula  from 
irremediable  obstruction,  anil  for  chohemia  and  its  tormenting  complications 
in  cancer  of  the  head  of  the  pancreas.  In  a  case  of  the  latter  kind  operated 
on  by  the  writer  the  patient  was  quite  promptly  relieved  of  the  chohemia  and 
its  inflictions,  and  lived  for  three  months  in  comparative  comfort. 

The  Operation. — Open  the  abdomen  through  a  vertical  incision  three 
inches  in  length,  located  at  the  outer  border  of  the  right  rectus  muscle  just 
below  the  ribs;  draw  apart  the  borders  of  the  wound  with  traction  sutures; 
carefully  examine  the  parts  and  raise  the  gall  bladder  and  duodenum  into 
the  wound  and  isolate  them  with  aseptic  pads ;  clear  the  intestine  selected  of 
its  contents  for  a  space  of 
three  or  four  inches  by 
digital  manipulation  and 
clamp  the  outer  limits  of 
the  space  ;  insert  a  needle 
armed  with  a  silk  liga- 
ture fifteen  inches  in 
length  into  and  through 
the  wall  of  the  duodenum 
opposite  the  mesentery 
and  near  the  head  of  the 
pancreas,  forming  a  stitch 
(purse-string)  one  third 
of  the  length  of  the  pro- 
posed opening  into  the 
gut ;  this  is  repeated  at 
the  same  side  and  reverse- 
ly on  the  other  w'ith  an 
intervening  loop,  as  indi- 
cated in  Fig.  816.  Make 
an  incision  in  the  intes- 
tine equal  in  length  to  two 
thirds  of  the  diameter  of  a  Murphy  button  of  proper  size  (three  quarters  of 
an  inch) ;  grasp  and  introduce  sidewise  one  cup  of  the  button  (Figs.  812  and 
813)  and  draw  the  suture  tightly  around  the  hub  and  tie  it;  aspirate  the 


Fig.  1017. — The  operation  of  cholecystenterostoiuy  with 
IMurphy's  button. 


812  OPKKATIVE   SniGERY. 

gall  bladder  and  introduce  a  similar  suture  at  its  most  convenient  aspect; 
incise  the  gall  bladder,  cleanse  it  and  introduce  the  remaining  cup  and  tie 
the  suture  as  before;  invaginate  the  hubs  (Fig.  1017)  and  press  the  cups 
firmly  together;  cleanse  the  parts,  return  them,  and  close  the  abdominal 
wound.  In  the  employment  of  tiie  Murphy  button  the  gall  bladder,  if  much 
distended,  should  be  treated  before  the  intestine,  for  the  sake  of  greater 
convenience  and  safety.  The  opening  into  the  former  should  be  so  placed 
as  to  readily  meet  the  intestine  without  the  distortion  of  either.  Careful 
isolation  should  be  practiced  to  prevent  the  danger  of  infection  incident  to 
removal  from  the  gall  bladder  of  calculous  and  inflammatory  contents.  The 
male  portion  of  the  button  can  be  employed  in  the  duodenum  more  con- 
veniently than  in  the  gall  bladder. 

The  Remarks. — The  serous  surfaces  to  be  approximated  are  sometimes 
scratched  to  hasten  the  union.  The  small  button  constructed  by  Murphy 
for  this  especial  purpose  has  no  rival  in  the  surgical  armamentarium.  The 
bone  bobbin  of  Eobson  can  be  used  with  promptness  and  security.  In  the 
absence  of  special  mechanism  the  union  may  be  established  by  sewing,  the 
same  as  in  intestinal  anastomosis  and  implantation.  The  anastomosis  with 
the  duodenum  conforms  to  the  natural  entry  of  bile  to  the  intestine  better 
than  an  anastomosis  with  any  other  portion  of  the  gut.  However,  whether 
the  increased  difiiculty  of  adjustment  with  this  intestine  in  some  instances 
is  met  by  a  corresponding  physiological  gain  is  open  to  reasonable  doubt. 
Anastomosis  with  the  flexure  of  the  colon  is  very  convenient,  and  thus  far 
has  seemed  quite  satisfactory.  Anastomosis  with  the  jejunum  and  ileum 
can  be  readily  practiced,  but  the  mobility  of  these  intestines  is  such  as  to 
invite  kinking  and  undue  traction,  to  say  nothing  of  volvulus. 

The  Results. — The  beneficent  agency  of  the  Murphy  button  is  attested 
by  the  loss  of  but  one  patient  (dependent  on  the  button  only)  in  38  opera- 
tions, while  by  other  means  36  per  cent  died.  Later  estimates  in  143  cases 
in  malignant  and  non-malignant  disease,  mostly  the  latter,  show  a  death  rate 
of  14.08  per  cent,  with  but  one  case  directly  attributable  to  the  use  of  the 
button. 

CholecysteJiter ostomy  can  be  practiced  by  means  of  sutures  onl}'  in  one, 
two,  and  three  stages.  In  either  instance  the  abdominal  incision  is  usually 
vertical,  three  or  four  inches  in  length,  and  located  at  the  upper  limit  of  the 
right  linea  semilunaris.  In  the  first  instance  the  gall  bladder  is  brought  into 
the  wound,  isolated,  and  the  contents  are  evacuated,  the  wall  is  incised  for 
half  or  three  quarters  of  an  inch,  the  cavity  irrigated  with  an  aseptic  solu- 
tion, packed  with  a  sponge  and  returned  to  the  abdomen.  The  duodenum 
or  jejunum,  usually  the  latter,  is  brought  into  the  wound,  the  contents  are 
pushed  aside  with  the  finger,  and  confined  there  by  means  of  broad  silk  trac- 
tion loops  passed  around  the  intestine.  A  longitudinal  opening  of  half  or 
three  fourths  of  an  inch  is  made  in  the  intestine  opposite  the  mesentery,  the 
gall  bladder  is  returned  to  the  wound,  the  sponge  removed,  and  the  borders  of 
the  incisions  in  the  respective  viscera  are  approximated  and  joined  together 
by  two  rows  of  sutures,  the  inner  uniting  the  mucous  borders,  the  outer  the 
musculo-serous  coats,  in  the  usual  manner.     After  removal  of  the  command- 


orKKATloNS   <)\    VISCKHA    CONXKC'I'KIt    WTI'll    I'llKl'ION  .1  :i'.M.     813 

ing  traction  sutures  tlie  parts  are  cleansed,  ii-tiirncd  tu  the  alxloiiien,  and  the 
incision  is  closed  in  the  usual  manner. 

In  opvratiun  hy  tiro  stages  the  gall  IjJaddcr  and  loop  of  intestine  are 
brought  into  the  wound,  and  contiguous  areas  of  each,  an  inch  long  and  half 
an  inch  wide,  are  ajiposed  and  joined  at  their  margins  hy  sutures  including 
the  serous  and  muscular  coats  of  the  respective  viscera.  The  approximated 
\  isci-ra  are  then  returned  and  stitched  to  the  bottom  of  the  abdominal  wound, 
anil  the  wound  itself  packed  with  gauze  for  five  or  six  days.  The  approxi- 
mated structures  are  then  raised  upward  sufficiently  to  permit  the  making  of 
an  incision  into  the  intestine,  a  short  distance  below  the  united  surfaces, 
when,  with  a  knife  or  cautery  passed  throngii  the  opening,  an  anastomosis  is 
made  by  freely  opening  the  apposed  areas  of  the  respective  organs.  Tlie 
divided  borders  of  the  mucous  membranes  of  the  structures  are  united  with 
a  tine  continuous  silk  suture,  the  incision  in  the  intestine  is  closed  in  the 
usual  manner,  the  parts  are  thoroughly  cleansed,  returned  to  the  belly,  and 
the  abdominal  wound  is  closed. 

In  operation  by  three  stages  the  gall  bladder  and  small  intestine  are 
sewed  together  as  in  the  preceding.  The  gall  bladder  is  then  drawn  into 
the  wound,  incised,  and  contents  are  evacuated,  the  margins  of  the  gall 
bladder  are  united  to  those  of  the  abdominal  incision,  the  excess  of  the 
abdominal  wound  is  closed,  and  dressings  are  applied  for  several  days;  then 
a  biliary  fistula  is  established.  Through  the  fistulous  opening  the  partition 
between  the  gall  bladder  and  the  intestine  is  divided  with  a  knife,  and  the 
borders  are  sewed  as  before,  thus  completing  the  second  stage.  After  three 
or  four  weeks  the  fistulous  opening  is  closed  by  a  plastic  operation,  thus 
completing  the  case. 

The  Remarks. — But  little  can  be  said  in  favor  of  these  methods  of  prac- 
tice, except,  perhaps,  that  they  may  prove  serviceable  in  the  forced  absence 
of  the  l)etter  and  more  acceptable  methods  by  mechanical  means. 

Cholecysto-lithotrity  consists  in  exposing  the  gall  bladder  and  crushing 
calculi  contained  within  it  by  means  of  the  fingers,  and  by  forceps  with  blades 
protected  by  rubber  (Fig.  1015)  or  other  suitable  agents.  The  fragments  are 
then  forced  through  the  cystic  into  the  common  duct,  thence  escape  into  the 
intestine.  In  the  instances  of  soft  and  pasty  stones  this  plan  of  action  may 
be  regarded  with  comparative  favor.  But,  when  the  stones  are  hard  and  the 
fragments  irregular,  the  danger  of  so  bruising  the  gall  bladder  as  to  cause 
subsequent  ulceration  and  perhaps  sloughing  of  its  wall,  followed  by  peri- 
tonitis, seems  to  forbid  a  general  application  of  the  plan.  Finally,  it  is  not 
at  all  certain  that  the  fragments  can  be  pushed  through  the  cystic  duct,  for 
Brewer  has  shown,  in  this  connection,  that  even  "  a  soft  metal  probe  "  can 
not  be  passed  through  the  cystic  duct  in  eight  per  cent  of  the  cases  contain- 
ing calculi  in  the  gall  bladder. 

The  Itesults. — RoJjson  reports  two  cases,  both  successful,  by  this  method. 

Cholelithotrity. — (.'holelithotrity  signifies  the  crushing  of  gallstones  in 
the  biliary  ducts.  Conrvoisier  and  Fenger  have  given  paiiistaking  consid- 
eration to  gallstone  in  its  practical  aspects.  The  stone  is  found  at  the  duo- 
denal end  of  the  duct  in  G7  per  cent,  at  the  hepatic  end  in  15,  and  at  the 


814  OPERATIVE  SURGERY. 

middle  in  18  per  cent  of  the  cases.  One  stone  is  present  in  two  thirds  of 
the  cases;  in  one  third,  two,  and  even  as  many  as  six  may  be  found.  In  the 
instances  of  single  stones  the  size  varies  from  one  to  four  fifths  of  an  inch  in 
diameter.  In  97  cases  of  cholelithiasis  stone  was  present  in  the  gall  bladder 
alone  in  8-4  per  cent,  in  the  gall  bladder  and  common  duct  in  10,  and  in  the 
common  duct  alone  in  5  per  cent  of  the  cases. 

The  Operation. — After  thorough  aseptic  preparation,  make  either  a  ver- 
tical incision  four  or  five  inches  in  length  from  the  ribs  downward  through 
the  outer  fibers  of  the  rectus  abdominis,  or  an  angular  one,  with  an  upper 
limb  three  inches  in  length  lying  close  to  the  ribs,  and  a  lower  one  of  about 
the  same  length  running  in  the  course  of  the  fibers  of  the  external  oblique. 
The  latter  method  of  entrance  affords  a  good  chance  for  observation ;  neither 
method  offers  any  special  inclination  to  weakness  of  the  abdominal  wall. 
A  straiglit  incision  beginning  an  inch  below  the  eighth  costal  cartilage  and 
passing  through  the  outer  border  of  the  rectus  muscle  to  a  point  two  inches 
above  the  umbilicus,  or  a  curved  one  beginning  at  a  point  just  below  and 
outside  the  ensiform  cartilage  and  passing  downward  and  outward  parallel 
with  the  costal  border  to  a  point  half  an  inch  above  the  tip  of  the  eleventh 
rib,  will  in  either  instance  expose  to  division  only  the  ninth  nerve.  The 
flaps  are  drawn  apart  with  traction  sutures  and  spatula?,  and  the  gall  bladder 
is  localized,  from  which  the  cystic,  hepatic,  and  common  ducts,  are  traced 
in  their  order  and  carefully  examined  for  stone.  Large  stones  can  be  easily 
located ;  small  and  floating  ones  are  difficult  to  detect  and  may  escape  the 
notice  of  the  most  expert  manipulation.  If  the  stone  be  movable  it  may  be 
pushed  along  the  common  duct  into  the  duodenum  with  the  thumb  and  finger. 
If  in  the  cystic  duct  it  may  defeat  removal  by  prompt  escape  to  the  hepatic 
duct.  If  the  stone  be  fixed  in  the  common  duct,  isolate  the  field  of  action 
from  the  peritoneal  cavity,  liver,  and  intestines,  by  careful  and  abundant 
sponge  or  gauze  packing ;  raise  upward  the  free  border  of  the  liver  to  afford 
ample  view,  then  crush  the  stone  by  thumb-and-finger  pressure,  or  bv  flat 
forceps  with  each  blade  covered  with  rubber  tubing  (Fig.  1015)  {clioledocho- 
IWiotrity) ;  or,  failing  with  these,  TaWs  plan  of  picking  the  stone  into  suit- 
able sized  pieces,  for  escape,  with  a  sharp  needle  passed  through  the  wall  of 
the  duct,  can  be  practiced.  During  the  latter  expedient  the  stone  is  grasped 
with  the  thumb  and  finger  to  prevent  its  escape,  and  also  to  estimate  and 
oppose  the  force  applied  by  the  needle.  If  the  stone  be  not  too  large  or  too 
hard,  but  little  harm  can  come  from  these  means  of  treatment.  After  crush- 
ing, the  operation  field  is  cleansed,  the  s^ionges  or  gauze  are  removed,  and  the 
abdominal  wound  is  closed,  if  there  be  no  doubt  as  to  the  final  integrity  of 
the  duct.  If  such  a  doubt  be  present,  iodoform  gauze  tents  are  carried  above, 
behind,  and  below  the  seat  of  the  injury,  and  allowed  to  escape  from  a  nar- 
rowed abdominal  wound,  remaining  for  two  or  three  days,  after  which  they 
are  removed,  leaving  a  fibrinous  track  for  the  escape  of  bile.  The  usual  asep- 
tic dressings  are  applied  and  anodynes  administered  for  the  relief  of  pain. 

The  Precautions. — Incautious  or  misdirected  manipulations  addressed  to 
a  movable  stone  located  in  the  cystic  or  common  duct  may  cause  the  stone 
to  disappear  instantly  into  the  hepatic   duct  beyond  the  reach  of  human 


OPKUATIONS   ON    VISCKltA    (ONN  KC'l'KI)    W  1111    I'KKIToX  JllM.     .Sl5 

resource  to  eutcli,  iiiul  for  tlie  time  defeat  tlic  i»in|i().se  of  the  oj)er5ition.  'I'lie 
iiutlior  lias  eneoiiiitereil  uii  iiistuiiee  of  this  kind  in  a,  stone  of  tlie  cystic  duct 
in  a  case  of  eholecystotomy.  Tlie  employnient  of  too  great  pressure  may 
cause  laceration  of  the  duct,  or  a  l)ruisiiig  that  will  be  foHowed  by  the 
sloughing  of  its  walls.  The  needle  jtuncture  of  the  duet  should  be  limited 
to  as  few  points  as  possii)le,  and  the  duodenal  as])ect  of  the  stone  should  be 
attacked  lirst  when  practicable,  to  hasten  the  removal  of  the  fragments, 
(luarded  pressure  should  be  made  to  prevent  the  needle  from  transfixing  the 
duct  and  passing  into  the  tissues  beyond.  If  the  duct  be  sacculated  these 
methods  are  objectional)le,  as  detritus  may  remain  in  the  expanded  part  and 
lead  quite  promptly  to  the  development  of  another  Cidculus  (Fenger). 

The  Remarks. — The  gall  bhidder  may  be  atroi)hied  and  inflammatory 
changes  may  have  caused  derangement  and  matting  of  the  tissues  to  such  an 
extent  as  to  perplex  ihe  surgeon.  However,  if  the  foramen  Winslowii  be 
patent,  the  introduction  into  it  of  the  index  finger  will  bring  the  common 
duct  between  the  finger  and  the  thumb,  and  thus  enable  one  to  manipulate 
the  duct  its  entire  length. 

The  liesuUs. —  Waring  reports  11  operations,  of  which  8  were  successful. 
Jlobsoii  reports  2G  cases,  all  of  which  were  successful. 

Choledochotomy  {CJtoledocho-liUtotomy). — Choledochotomy  consists  in 
cutting  into  the  common  bile  duct  for  the  purpose  of  removing  a  gallstone. 
The  cystic  {cystico-UtJiotomn)  and  hei)atic  {liepaticDstoiny)  ducts  can  be 
opened  for  the  same  })urpose  and  in  a  similar  manner,  and  therefore  can  be 
regarded  under  the  same  heading.  The  abdominal  incision,  localization  of 
the  stone,  etc.,  are  somewhat  similar  to  like  steps  in  cholelithotrity.  The  gall 
bladder,  cystic,  and  cofnmon  ducts  should  be  examined  carefully  in  the  order 
mentioned,  the  last  noted  especially  in  its  relations  with  the  head  of  the  pan- 
creas and  inner  aspect  of  the  descending  portion  of  the  duodenum.  In  fact, 
the  explorative  and  operative  procedures  are  similar  until  opening  of  the 
duct  is  determined  upon. 

The  Operation. — As  soon  as  the  calculus  is  discovered  in  the  common 
duct,  the  lesser  omentum  and  the  duct  are  drawn  into  the  abdominal  wound 
and  the  field  of  operation  is  isolated  thoroughly  with  gauze  pads.  Seize  the 
duct  with  the  stone  by  the  thumb  and  finger;  make  an  incision  down  upon 
the  stone  in  the  long  axis  of  the  duct  of  sufficient  length  to  permit  its  dis- 
lodgmeut ;  raise  the  stone  out  with  forceps  or  scoop  and  remove  it ;  wipe 
away  the  escaping  bile  and  blood  carefully;  introduce  a  probe  through  the 
opening  into  the  duct  and  sound  it  in  either  direction  for  the  presence  of 
other  stones;  pass  the  probe  into  the  duodenum  to  insure  the  patency  of  the 
duct;  cleanse  again  the  field  of  ojieration  ;  close  if  practicable  the  incision 
in  the  duct  by  means  of  two  rows  of  fine  sutures,  the  first  including  the  wall 
down  to  the  mucosa,  the  second  the  serous  covering  only.  Halsted*  in 
commenting  on  suture  of  the  bile  ducts,  expressed  himself  as  follows  :  "  Sur- 
gery of  the  common  bile  duct  is  still  in  its  infancy."  Further  along,  in 
speaking  of  the  utterances  of  others  regarding  the  "great  diflticulty"  and 


*  .Johns  Hopkins  Ilosiatal  P.ullctin,  April,  1898. 


816 


OPERATIVE    SURGERY. 


"impossibility  of  sewing  the  duct,"  he  brought  to  tlie  attention  of  the  pro- 
fession the  use  of  the  hammers  devised  by  liimself  for  the  purpose,  saying, 
"  If  properly  employed  they  convert  one  of  the  most  diflicult  operations  in 
surgery  into  quite  a  simple  one."  Hahted  exposed  the  duct  at  the  site  of 
the  proposed  incision,  preferably  nearer  the  duodenal  end  because  of  the 
greater  convenience  and  better  opportunity  to  explore  the  diverticulum  of 
Vater  thus  afforded.  Two  traction  loops  are  tiien  introduced  through  the 
walls  of  the  duct,  one  at  either  side  (Fig.  1018),  the  duct  is  incised  longitudi- 
nally between  them,  the  stone  removed,  the  duct  raised  from  its  bed,  and 
the  incision  opened  by  the  traction  loops;  the  hammer  is  introduced  (Fig. 
1019),  pressed  downward,   the  duct   raised  by  traction  loops,  and   mattress 


\\\\V  «\\^W\' 


Fjg.  1018. — The  operation  of  choledoehot- 
omy,  Halsted's  method.  Traction  loops 
at  the  sides  of  longitudinal  incision. 


Fig.  1019. — The  operation  of  ehuledochot- 
omy,  Halsted's  method.  Introducing 
the  hammer. 


sutures  are  applied,  one  over  the  heel  of  the  hammer,  the  remainder  at  the 
opposite  side  of  the  handle  (Fig.  1020). 

The  advantages  of  the  hammer  are  thus  expressed  by  Halstcd  : 

"1.  The  duct  to  be  sutured  can  be  drawn  toward  the  incision  in  the 
anterior  abdominal  wall  and  within  easy  reach  of  the  operator;  it  can  also 
be  manipulated  nicely  by  the  hammer. 

"  2.  The  duct,  whether  normal  or  thickened  and  dilated,  is  gently 
expanded  by  the  hammer ;  hence  the  stitches  can  be  taken  with  great  accu- 
racy and  without  fear  of  including  the  opposite  wall  or  of  occluding  the 
lumen  of  the  duct. 

"3.  The  operation  is  a  very  clean  one,  because  the  liammer  blocks  the 
duct  and  this  prevents  the  escape  of  its  contents  and  the  contents  of  the 
gall  bladder. 

"4.  With  the  hammer,  wounds  of  thin  normal  ducts  can  be  easily  and 
almost  infallibly  sutured,  and  hence  the  surgeon  may,  if  he  chooses,  fearlessly 
operate  upon  the  common  duct  as  soon  as  the  obstruction  takes  place. 

"  The  sewing  of  the  thickened  and  dilated  ducts  is  also  greatly  facilitated 
by  the  employment  of  the  hammer." 


ui'KiLvrioNs  UN  visi'Ki:a  c'(»nm:('ti-:i»  wijh  rKuiToxja'M.    {^17 


Tlie  silk,  the  needles,  juul  the  needle-holder  are  eiich  especially  provided 
for  the  operation  (i^'iij:.  KM")).  A  series  of  hanuners  with  long  delicate  han- 
dles are  included  rn  the  oiitlit. 


Fici.    \{}'20. — The   openition   of   cholcdochotomy,   Halsted's    method.      Mattress    sutures 
placed  and  haiiiiner  in  position. 

If  the  walls  of  the  duct  be  insecure  for  any  reason,  or  the  condition  of 
the  patient  forbid  prolongation  of  the  operation,  sewing  should  be  omitted 
and  drainage  provided  instead,  by  introducing  into  the  duct  a  small  rubber 
or  glass  drainage  tube,  around  which  is  carefully  and  smootlily  placed  rubber 
tissue  or  iodoform  gauze  so  adjusted  at  all  aspects  of  the  tube  and  duct  as  to 
prevent  escape  of  bile  into  the  peri- 


toneal cavity.  The  difficulty,  pain, 
and  disturbance  of  parts  so  often 
attending  the  withdrawal  of  iodo- 
form gauze  from  the  tissues,  sug- 
gests that  this  form  of  gauze  be 
dispensed  with  when  practicable  C 
and  that  rubber  tissue  be  substi- 
tuted. If  this  gauze  be  employed,  Fic  I021.-The  operation  of  chole- 
,  ,  .       .        ,,/.«,  1  dociiotoniv.     A  plan  of  drainage 

the    objectionable    leafures  can    be        practiced  by  Abbe. 

remedied  by  saturation  with  steril- 
ized oil  before  introduction  and  again  before  removal,  or  perhaps 
quite  as  well  by  interposing  between  the  gauze  and  the  raw 
surfaces  rubber  tissue.  Abbe  introduced  into  the  hepatic  duct 
through  the  opening  in  the  common,  a  drainage  tube,  over  which 
a  larger  tube  was  passed  up  to  the  opening  in  the  duct,  and  out 
side  long  strips  of  iodoform  gauze  were  lightly  introduced  (Fig.  1021). 
The  inner  tube  was  reinoved  on  the  second  day,  the  outer  on  the  fifth, 
the  bile  passing  through  them  during  their  presence  in  the  wound.     The 


n-" 


jHlS  OPERATIVE  SURGERY. 

sinus  closed  finally  in  three  weeks.  Approximation  of  the  borders  of  the 
incision  with  a  single  suture,  or  by  gauze  })ressure  plus  the  properly  ad- 
justed gauze  drainage,  answers  the  purpose  quite  well  indeed.  Under  all 
circumstances  some  form  of  drainage  should  be  employed  and  the  external 
wound  should  not  be  finally  closed  until  all  danger  of  biliary  discharge  has 
disappeared.  Morison  advised  drainage  through  a  punctured  wound  carried 
posteriorly  below  the  kidney.  Fenger  regards  the  introduction  of  the  tube 
into  the  incision  and  the  insertion  of  gauze  drainage  above  and  below  the 
tube  as  quite  sufficient.  Kehr  in  two  cases  opened  the  abdomen  in  the 
median  line  between  the  xiphoid  cartilage  and  the  umbilicus,  to  remove 
from  the  cystic  duct  gallstones  that  resisted  removal  from  below  through  a 
previously  existing  mucous  biliary  fistula.  The  wound  of  the  duct  was 
closed  at  once  and  drainage  secured  through  the  already  established  fistula. 
The  presence  of  an  impacted  stone  in  the  environment  of  the  duodenal  end 
of  the  duct  or  in  the  ampulla  of  Vater  often  requires  incision  of  the  wall  of 
the  gut  to  secure  its  release  {internal  choledoclio-duodetiostouiy).  McBurney 
and  others  have  met  instances  of  this  kind.  With  the  finger  in  the  intestinal 
incision  the  end  of  the  duct  may  be  dilated  and  the  stone  pushed  into  the 
bowel,  or  it  may  be  pushed  upward  farther  into  the  duct  and  be  removed  by 
incision  from  without  or  left  alone  and  extracted  from  within,  as  seems  best. 

Tlie  Precautions. — Infinite  care  should  be  exercised  in  the  detection  of 
the  site  and  the  exposure  of  calculi,  otherwise  the  contiguous  vessels  will  be 
damaged  or  opened ;  and  especially  is  this  true  when  extensive  adhesions 
with  consequent  displacements  are  present,  notably  so  near  the  duodenal  ex- 
tremity. In  the  latter  instance  the  gut  should  be  carefully  pushed  aside  and 
the  wound  deepened  by  blunt  dissection.  The  colon  may  be  invaded  in  rare 
instances.  Incisions  into  the  cystic  duct  should  be  made  either  at  the  ante- 
rior or  posterior  surface,  to  avoid  the  cystic  artery  (Fig.  1013)  and  portal 
vein.  The  security  of  the  hepatic  artery  and  portal  vein  requires  that  inci- 
sions be  made  in  the  long  axis  of  the  remaining  biliary  ducts  (Fig.  1014).  It 
should  not  be  overlooked  that,  although  healthy  bile  is  aseptic,  the  influences 
incident  to  the  presence  of  calculi  in  the  ducts  may  establish  infection  of  a 
serious  nature,  causing  peritonitis,  therefore  careful  arrangement  of  gauze 
tents  at  all  aspects  of  the  wound  should  be  made  to  prevent  peritoneal 
extravasation  of  bile.  If  the  escape  of  bile  into  the  peritoneal  cavity  be  free 
it  may  invade  Douglas's  pouch  and  require  removal  by  means  of  a  tube  intro- 
duced through  an  opening  made  above  the  pubes.  According  to  Morison  it 
readily  collects  in  the  limited  space  between  the  right  lobe  of  the  liver  and 
the  colon,  from  which  it  may  be  efficiently  drained  by  a  curved  incision 
extending  from  a  little  below  the  tip  of  the  ninth  rib  to  the  loin,  and  even 
to  the  outer  edge  of  the  quadratus  lumborum  muscle  if  additional  space  be 
required.  After  three  or  four  days  the  gauze  may  be  removed  and  the  rubber 
tube  allowed  to  remain  for  a  week  or  so  longer.  The  fibrinous  canal  formed 
along  the  course  of  the  gauze  will  meet  the  additional  requirements  of  drainage. 

The  Remarks. — Either  the  continuous  or  interrupted  varieties  of  sewing 
of  the  duct  can  be  employed  ;  usually  the  former  is  selected.  Fine,  strong 
catgut  or  silk,  and  sometimes  both  are  used,  the  catgut  being  employed  for 


Ul'HKATlONS  ON   VISCKUA   CUNNKCTKl)   WITH    I'KiilTUxN .KL'M.     811) 


the  iirst  row  in  the  latter  instance.  Many  .snrgeons  rely  on  a  siiiffje  row  of 
sutures  only.  l''inc  curved  rouml  nei'dles  and  a  lon<(  needle  holder  are  the 
best  of  the  common  varieties  for  use  in  sewing  (I*'ig.  1015,  a).  Siphonage  i.s 
applied  not  infrecjuently  to  the  drainage  tube,  but  the  action  is  so  fickle  and 
so  easily  disturbed  as  to  render  it  of  uncertain  utility.  Tiu!  removal  of  the; 
gall  bladder  {r/ioleri/s/rchnif/)  together  with  a  ]>ortion  of  the  duct  containing 
a  calculus  so  firmly  impacted  that  it  can  not  be  wisely  dislodged  by  manij)u- 
lation  upward  or  downward  is  advisal)le  when  the  structural  changes  in  the 
duct  at  the  seat  of  im})action  are  such  that  incision  (ri/slico-li/J/o/o/ii//)  is  quite 
sure  to  be  followed  by  oblitera- 
tion of  the  duct  and  consequent 
distention  of  the  gall  bladder  by 
its  mucous  secretion.  However, 
if  the  walls  of  the  duct  are  suf- 
ficiently healthy  to  iiermit  jirojier 
closure  of  the  incision  by  sewing, 
this  latter  plan  is  commendable. 
Elliot  advises  that  a  small  sand 
bag  be  placed  beneath  the  back 
while  the  body  is  maintained  at 
an  angle  of  forty- live  degrees 
by  straps  nnder  the  arms.  Thus 
the  intestines  gravitate  toward 
the  pelvis,  and  with  the  liver 
raised  np  improved  observation 
is  gained.  Pressure  on  the  duct 
above  the  stone  with  the  fingers,  before  the  incision  is  made,  will  prevent 
the  free  escape  of  bile  when  the  stone  is  removed  (Fig.  1022) ;  and  at  this 
time  the  patency  of  the  duct  beyond  can  be  determined  with  a  probe,  and 
also  the  sutures  may  be  laid  before  the  stone  is  raised  from  its  bed  (Elliot). 
Traction  loops  introduced  at  either  side  of  the  duct  (Fig.  1018)  before  mak- 
ing the  incision  are  of  great  use  in  the  introduction  of  the  sutures.  How- 
ever, one  should  cautiously  observe  before  the  opening  is  closed  that  no 
calculi  remain  behind.  Occasionally  an  obstructed  common  duct  becomes 
very  much  overdistended,  suttieiently  in  fact  to  cause  a  tumor  of  pronounced 
character.  In  a  case  of  this  kind,  Winiwarter,  through  an  incision  in  the 
linea  semilunaris,  established  a  communication  between  the  dilated  duct  and 
the  cutaneous  surface  {choledochostoniy) .  The  patients  thus  far  treated  by 
this  method  have  succumbed.  Sprenyel  anastomosed  successfully  a  greatly 
dilated  common  duct  with  the  duodenum  {choledocho-enterostomy)  (page  820). 

Choledochotomy  {Lnmhar  Eoute). — Posterior  or  lumbar  choledochotomy 
was  studied  from  its  theoretical  side  by  Tuffier  and  Poirier  (1895).  The 
lumbar  route  has  been  practically  utilized  in  man  by  Wright,  Mears,  Lange, 
Bogajesky,  and  several  others. 

Tlic  Operation. — Place  the  patient  on  the  left  side,  raising  the  right  by 
a  cushion  under  the  flank;  make  an  incision  over  the  right  lumbar  region, 
as  in  extirpation  of  the  kidney.     Expose  the  kidney  and  colon,  isolate  the 
58 


Fig.  1023. — The  operation  of  choledochotomy. 
Compression  of  duct,  exi)osure  of  stone,  and 
phicing  of  sutures. 


820  OPERATIVE   SURGERY. 

upper  extremity  of  the  kidney,  and  raise  and  hold  it  against  the  false  ribs 
by  the  fingers  or  a  retractor ;  seek  for  the  duodenum,  first  exposing  the 
ascending  portion,  then  the  second  i)ortion,  and  finally  the  pancreas. 
Carry  inward  and  shield  the  vena  cava  inferior,  while  the  second  portion 
of  the  duodenum  is  pressed  outward;  introduce  the  left  index  finger  into 
the  wound,  pulp  inward,  and  expose  the  "  vasculo-biliary  mass "  as  it  de- 
scends from  the  liver  (Tuffier),  or  obtain  a  view  of  the  bottom  of  the 
wound,  and  locate  and  isolate  a  large  cordlike  mass  descending  from  the 
liver  toward  tlie  duodenum,  consisting  of  two  or  three  lym])hatic  gang- 
lia, large  veins,  the  posterior  branch  of  the  pancreatic-duodenal  artery, 
and  the  gall  duct.  In  either  instance  isolate  and  denude  the  duct  in  its 
retroduodenal  and  intrapancreatic  portion,  by  the  aid  of  long  forceps  and 
a  grooved  sound,  as  far  as  possible  without  opening  the  peritongeum. 
Determine  the  situation  of  the  calculus  and  incise  the  biliary  canal.  Ee- 
move  the  calculus,  cleanse  the  parts,  and  otherwise  treat  the  case  as  before 
practiced. 

The  Complications. — The  kidney  may  give  rise  to  obstacles,  especially  if 
it  is  a  movable  kidney,  wdiich  often  occurs  on  the  right  side.  In  elderly 
women  a  degree  of  superfluous  fat  may  render  difficult  the  localization  of 
the  short  portion  of  the  duct.  But,  as  the  operation  would  naturally  be  per- 
formed for  a  calculus,  the  latter  would  assist  in  the  recognition  of  the  dilated 
duct.  In  working  at  such  a  depth  there  is  great  danger  of  accident,  espe- 
cially of  opening  the  portal  vein  (Fig.  1014).  It  is  evident  that  when  the 
second  part  of  the  duct  is  alone  attacked  the  operation  is  extraperitoneal, 
which  is  a  great  advantage,  doing  away  with  the  need  of  intraperitoneal 
sutures. 

The  operation  is  comparatively  impracticable  and  unsatisfactory,  and  ill- 
adapted  to  the  exigencies  of  surgical  practice.  The  biliary  passages  as  a 
whole  can  not  be  explored  by  the  lumbar  route.  This  form  of  intervention 
can  be  defended  only  in  those  cases  where  it  is  necessary  at  all  hazard  to 
reach  the  duct  without  going  between  the  liver  and  duodenum. 

The  Remarks. — As  we  now  have  an  excellent  way  of  reaching  the  duct 
from  in  front,  the  operation  of  lumbar  choledochotomy  should  not  be  at- 
tempted except  for  some  s^jecial  purpose.  Tuffier  i-ecommends  the  incision 
employed  in  lumbar  nephrectomy — one  finger's  breadth  below  and  parallel 
with  the  twelfth  rib.  Poirier  says  the  incision  should  be  carried  to  the  iliac 
crest.  The  second  part  of  the  duodenum  is  identified  by  the  absence  of 
peritomeum  on  its  posterior  surface. 

The  Results. — The  general  death  rate  of  choledochotomy  varies  from 
20  to  44  per  cent,  the  special  from  8  to  25  per  cent. 

Choledocho -enterostomy  can  be  done  with  buttons  of  small  size,  such  as 
those  used  by  Boari  in  uretero-anastomosis  (Fig.  1023)  in  a  choledochus  duct 
which  is  very  slightly  dilated  (Fig.  1024),  and  this  in  certain  cases  in  which 
it  would  be  impossible  to  apply  sutures  (Fig.  1025). 

Alessandri  has  recently  contrived  a  button  which  is  nothing  more  than 
a  slight  modification  of  Boari's.  The  terminal  portion  of  the  apparatus  is 
so  formed  that  it  can  be  "  hooded  "  within  the  stump  of  the  choledochus 


orKRATlOXS   UN    VISCHUA   CONNECTED    WITH    J'EUITUN J:L'M.     a^i 

duct,  and  the  inferior  portion  is  of  iin  ellipsoid  form.  To  manipuhite  the 
5ip]mratns  tiie  stylet  which  serves  to  separate  the  tissues  may  be  round  instead 
of  ovoid  or  quadrangular,  for  in  this  way  the  button  can  not  turn  upon  its 


''ici.  I02o. — I'liu  tipuni- 
tioii  of  choledocho- 
enterostoiuy,  Boari's 
button  in  {)osition, 
tr.'insverse  section. 
a.  Intestine,  b.  Com- 
mon (hiet.  c.  Intes- 
tinal wall. 


Fui.  1024. — The  operation  of 
choledocho  -  enterostomy, 
Boari's  button  in  posi- 
tion, a,  a'.  End  of  purse- 
string  suture,  b.  Com- 
mon duct.     c.  Intestine. 


Fig.  1025. — The  operation  of 
choledocho  -  enterostomy, 
Boari's  button,  operation 
completed,  a.  Intestine. 
b.  Common  duct. 


axis.  Besides,  this  button  is  provided  at  its  extremity  with  a  flange  which 
allows  it  to  be  grasped,  and  which  is  analogous  to  that  of  an  ordinary  can- 
nelated  sound.  The  manoeuvre  of  introducing  the  sound  is  accomplished 
readily  and  rapidly. 

Surely  cholecystenterostomy  is  preferable  to  either  of  these  procedures, 
provided,  of  course,  that  the  cystic  duct  be  patent.  Waring  considers  the 
advisability  of  excision  of  a  portion  of  the  common  duct  {choledochectomy), 
combined  with  cholecystenterostomy,  in  localized  malignant  disease  of  the 


Fig.  1026.— The  operation  of  resection-choledochorraphv,  Doyen's  method.     The  hepatic 
(a)  and  duodenal  (a)  end  of  duct.     The  remnants  (b,  b')  of  disorganized  portion  of 


(a) 
duct. 


The  flaps  (c,  c)  of  peritoneal  and  near-by  connective  tissues. 


duct  or  extensive  papillomata  of  its  mucous  membrane  and  extensive  ulcer- 
ative and  inflammatory  changes  of  its  structure.  He  suggests  the  removal 
of  the  diseased  portion  by  transverse  division  and  the  treatment  of  the 
divided    ends    by  cautery  or  scraping.     The  peritonaeum  should    then   be 


822 


OPERATIVE  SURGERY. 


Fig.  1037. — The  operation  of  resectioji-choledochorra- 
phy,  Doyen's  method.  The  hepatic  (a)  and  duode- 
nal («')  end  of  tube.  The  remnants  (b,  b')  of  the 
disorganized  portions  of  duct.  The  flaps  (c,  c)  of 
peritoneal  and  near-l)y  connective  tissues,  d.  The 
rubber  tube  in  position. 


stitclied  over  the  space  occupied  by  the  resected  part  for  purposes  of  repair 
of  the  duct  and  cliolecysteuterostomy  performed.  Waring  jjracticed  suc- 
cessfully   on    a    dog    this 


resourceful  plan.  Chole- 
dochectomy,  like  the  im- 
mediately jirecediiig  oi)er- 
ations,  has  fortunately  but 
a  limited  though  urgent 
field  of  utility. 

Resection  -  choledochor- 
rJuq)hy  (Doyen).  —  The 
flaps  forming  the  pocket 
which  contained  the  cal- 
culus are  utilized  for  the 
purpose  of  this  ojieration 
(Fig.  1026). 

The  Operation. — After 
being  assured  of  the  permeability  of  the  duct,  a  tube  of  red  rubber  is  in- 
serted, one  half  in  the  hepatic,  the  other  half  in  the  duodenal  side  (Fig. 
1027),    while    the    torn  ^ 


ends  of  the  canal  are 
approximated  by  a  glov- 
er's suture  (Fig.  1038). 
The  peritoneal  laminee 
and  near-by  connective 
tissues  are  carried  around 
the  preceding  suture  and 
nnited  (Fig.  1029),  and 
the  second  suture  is  re- 
enforced  by  a  few  wholly 
superficial  ones. 

The  Remarks. — This  surgical  attempt  is  cited  more  because  of  the  nov- 
elty than  the  practicability  of  the  endeavor.  The  absence  of  any  provision 
for  the  removal  of  the  tube  and  the  probable  opportunity  to  implant  the 
hepatic  end  (Fig.  1023)  into  the  intestine,  followed  by  closure  of  the  duode- 
nal end,  offers  a  ra- 


^ 


Fig.  1028. — The  operation  of  resection-cholcdochorrha- 
phy,  Doyen's  method.  The  hepatic  {a)  and  duodenal 
{a)  end  of  duct.  The  duct  flaps  (d)  turned  over  tube 
and  united  (e).  The  flaps  of  peritoneal  and  near-by 
connective  tissues  (c,  c). 


Fig.  1029. — The  operation  of  resection-choledochorraphy,  Doy- 
en's method.  The  hepatic  (a)  and  duodenal  [a!)  end  of 
duct.  The  flaps  (c,  c)  of  peritoneal  and  near-by  connective 
tissues  united  together  and  to  the  tube  (/). 


tional  escape  from 
the  dilemma  with- 
out entertaining  a 
serious  consideration 
of  the  former  plan. 

The  Res  Hits.  — 
Doyen's  patient  suc- 
cumbed on  the  sec- 


ond day.     Bile  had  passed  along  the  tube  and  no  evidence  of  inflammation 
was  present  on  autopsy. 

Reynier  operated  successfully  on  a  dog  by  this  method. 


(H'KUATIONS   (»N    VlSCKKA   CONXKCTKI)    W  ITll    1'KK1T<)NM;LM.     823 


Resection  of  the  Border  of  the  Thorax. — If,  in  connection  with  luparoto- 
niv  for  abtloniinal  wounds,  in  c.xccplioiial  cases,  in  operation  on  tiie  iicpatic 
ducts,  and  in  exploration  of  the  liver,  the  space  is  too  limited  for  suitable 
manipuhition  and  wise  operative  practice,  resection  of  the  costal  cartilages 
maybe  performed  (Figs.  1030  and  1031).  In  thoracico-abdominal  wounds 
the  transpleuro-pcritoneal  route  may  be  combined  with  the  abdominal  (c). 
The  forcible  drawing  upward  of  the  liver,  along  with  the  costal  border  of 
the  thorax,  together  with  the  support  gained  by  the  passage  of  the  finger 
througli  the  foramen  of  Winslow,  will  increase  markedly  the  opportunities 


Fig.  1030. — The  resection  of  costal  border. 
a.  Scapula,  b.  Axillary  line.  c.  Trans- 
pleuro-peritoneal  route,  d.  Incision  for 
resection  of  costal  margin. 


Fig.  1031. — The  resection  of  costal  border. 
a.  Median  line  incision,  b.  Incision  in 
right  linea  seniihinaris.  c.  Incision  for 
resection  of  costal  margin. 


for  action  in  gall-duct  surgery.  The  location  of  the  incision  and  the  extent 
of  the  costal  resection  are  decided  by  the  site  of  the  wound  or  of  the 
disease  and  the  needs  of  explorative  examination.  After  separation  of  the 
diaphragm  and  transversalis  muscles  from  the  costal  border,  it  is  resected 
and  turned  to  suit  the  convenience  of  the  operator.  Lange  regards  resec- 
tion as  indicated  in  operations  for  gallstones  where  the  liver  is  very  small 
and  located  high  up  beliind  the  ribs,  also  where  the  liver  is  enlarged, 
especially  in  fat  persons  and  those  of  compact  build,  to  facilitate  access  to 
the  common  and  cystic  ducts.  In  a  successful  case,  after  resection  it  was 
necessary  to  draw  upward  through  the  wound  about  a  third  of  the  liver 
before  he  could  safely  remove  the  calculus.  Hahted  speaks  highly  of  the 
aid  which  resection  of  the  cartilages  often  affords  in  operations  on  the  bile 
ducts. 

Biliary  Fistula. — Biliary  fistula  not  infrequently  is  a  troublesome  sequel 
of  cholecystostomy,  dependent  usually  on  obstruction  of  the  common  duct, 
due  to  calcuhjs  and  to  malignant  disease  of  the  head  of  the  pancreas.  If  from 
the  former  cause,  the  obstacle  should  be  removed  through  a  free  incision  by 
one  of  the  various  measures  directed  to  the  purpose.  Failing  in  this,  chole- 
cyst-enterostomy,  or  implantation  of  the  hepatic  end  of  tlie  duct  into  the 
intestine,  may  be  considered.  If  from  the  latter  cause,  cholecyst-enterostomy 
offers  the  best  solution  of  the  problem  (page  811). 


824 


OPERATIVE   SURGERY. 


OPERATIONS    ON   THE    KIDNEYS. 

The  Anatomical  Points. — A  horizontal  line  corresponding  in  front  to 
the  nmbilicns  is  below  the  lower  edge  of  the  kidney.     Therefore,  when  the 

kidney    extends    below    this 


line,  it  is  either  of  abnormal 
length  or  is  displaced  down- 
ward. A  vertical  line,  extend- 
ing from  the  middle  of  Pou- 
part's  ligament  to  the  ribs, 
crosses  the  kidney  in  its  long 
axis,  one  third  of  the  kidney 
lying  to  the  outer  and  two 
thirds  to  the  inner  side  of  the 
line.  The  outer  border  of 
the  erector  spina3  muscle  may 
be  regarded  as  the  superficial 
guide  to  the  kidney  and  the 
quadratus  lumborum  muscle 
the  deep  guide,  the  kidney  ly- 
ing in  front  of  the  latter  (Figs. 
1032  and  1033).  A  line  drawn 
from  the  spinous  process  of 
the  eleventh  dorsal  vertebrae 
horizontally  outward  marks 
the  site  of  the  upper  end  of 
the  left  kidney,  and  a  point  two  inches  above  the  crest  of  the  ilium  of  the 
same  side  indicates  the  site  of  the  lower  end.  The  right  kidney  is  about  half 
to  three  quarters  of  an  inch  lower  than  the  left.  The  hilum  lies  at  a  point 
located  about  two  inches  from  the  median  line  of  the  back,  and  on  a  level 
with  the  spinous  process  of  the  first  lumbar  vertebra.  It  follows,  therefore, 
that  the  eleventh  and  twelfth  ribs — more  especially  the  latter — intervene 
between  the  upper  part  of  the  kidney  and  the  external  world.  Hence  these 
ribs — particularly  their  anterior  extremities — may  be  taken  as  the  direct  guide 
to  manipulation  of  the  upper  part  of  the  kidney,  by  pressure  made  directly 
backward  from  the  front.  Parts  of  the  duodenum  and  colon  lie  in  front  of 
the  right  kidney,  and  the  upper  end  is  subperitoneal.  The  stomach  overlies 
the  upper,  the  pancreas  the  middle,  and  the  colon  part  of  the  lower  portion 
of  the  left  kidney.  The  upper  portion,  and  mainly  the  lower,  are  covered 
with  peritonaeum,  but  the  middle  not  at  all.  The  renal  arteries  lie  in  front 
of  the  associate  veins  more  often  than  is  usually  depicted.  Double  renal 
veins  are  more  frequent  than  are  double  renal  arteries.  A  branch  of  the 
renal  artery  or  vein  runs  across  the  back  of  the  renal  pelvis,  and  small 
branches  of  the  renal  artery  that  anastomose  with  the  lumbar  vessels  are 
close  at  hand.     These  vessels  may  be  wounded  in  ligature  of  the  pedicle. 

After  the  tenth  year,  and  seldom  before  this  time,  the  kidney  is  sur- 
rounded by  a  fatty  capsule  the  thickness  of  which  is  proportionate  to  the 


Fig.  1032. — The  surgical  anatomy  of  the  left  kidney. 
a.  External  oblique  muscle,  h.  Internal  oblique 
muscle,  c.  Transversalis  muscle,  d.  Trapezius 
muscle,  e.  Kidney.  /.  Erector  spina^  muscle. 
g.  Quadratus  lumborum  muscle,  /t.  Descend- 
ing colon,  i.  Fascia  lumborum,  anterior  layer. 
j.  Latissimus  dorsi  muscle,  h.  Transversalis 
muscle. 


Ul'EliATlOXS   U\    VISCKUA    CONXKCTEI)   WITH    PKRITON.EUM.     ^25 


(legrco  of  adiposity  of  the  patient  (1^'igs.  10.'}.']  and  1034).  IIoll  and  iMiige 
luive  emphasized  the  itnportanco  of  tiio  rehitions  of  the  twelfth  ril;  and 
plcnra  in  operations  on  the  kidney  in  no  uncertain  manner.  Normally  tiie 
lower  limit  of  the  pleura  corresponds  to  a  line  extending  between  the  lower 
borders  of  the  twelfth  dorsal  vertebra  and  the  eleventh  rib.  The  twelfth  rib 
may  be  absent,  or  so  rudimentary  as  to  escai)e  notice,  therefore  the  eleventh 
may  be  mistaken  for  it,  with  obvious  outcome  in  extended  operative  pro- 
cedure directed  to  the  supposed  twelfth  rib.  When  this  rib  is  rudimentary 
the  jileura  descends  as  low  as  when  of  normal  length. 

JfelsoHie  has  pointed  out  the  fact  that  when  the  twelfth  rib  extends 
beyond  the  outer  border  of  the  erector  spinge  muscle  an  incision  reaching  to 
the  angle  of  the  crossing  does  not  endanger  the  pleura  except  when  the  mus- 
cle is  cut  into  or  pulled  aside,  thus  changing,  perhaps  needlessly,  the  normal 
relations  of  the  parts.  However,  in  the  absence  of  this  rib,  or  its  failure  to 
cross  the  muscle,  the  trusty  angle  is  not  present,  but  instead  a  deceptive  one 
is  formed  higher  up  by  the  eleventh  instead  of  the  twelfth  rib. 


IfCfl 


Fig.  1033. — The  surgical  anatomy  of  the  left  kidney,  transverse  section,  a.  External 
oblique  muscle,  b.  Internal  "oblique  muscle,  c.  Transversalis  muscle,  d.  Fascia 
ti-ansversalis  and  peritonanun.     e.  Anterior,  middle,  and  posterior  of  lumbar  fascia. 

If  this  fallacy  be  not  determined  by  previous  counting  of  the  ribs,  from 
above  downward,  the  pleural  cavity  is  almost  certain  to  be  invaded.  But  lat- 
erally, on  the  left  the  pleura  extends  to  within  an  inch  and  a  half  of  the 
costal  margin ;  on  the  right  to  within  two  inches. 

Nephropexy. — Nephropexy  (nephrorrhaphy)  is  an  operation  directed  to 
the  fixation  of  a  troublesome  movable  or  floating  kidney.  The  former  con- 
dition is  quite  common  and  usually  acquired ;  the  latter  is  rare  and  congeni- 
tal. The  right  kidney  is  mobile  much  more  frequently  than  the  left;  both 
may  be  similarly  affected  together,  the  left  rarely  alone. 


826 


OPERATIVE   SURGERY. 


lite  Operation. — Place  tlie  patient  with  the  sound  side  resting  on  a  hard 
pillow  so  as  to  make  the  field  of  operation  convex  and  to  increase  the  dis- 
tance between  the  last  rib  and  the  crest  of  the  ilium  (Figs.  103G  and  1037) ; 
locate  the  twelfth  rib  and  half  an  inch  below  at  the  outer  border  of  the  erector 
spinae  begin  the  incision  (Figs.  1043,  perpendicular  C,  1032,  and  1033) ;  carry 
the  incision  downward  along  the  outer  border  of  the  sheath  of  this  muscle, 
which  should  not  be  opened,  toward  the  iliac  crest  for  three  or  four  inches; 
divide  the  superficial  tissues  down  to  the  posterior  border  of  the  latissimus 
dorsi  (Figs.  1032  and  1033) ;  draw  forward  the  fibers  of  this  muscle  and  divide 


Fig.  1034. — The  surgical  anatomy  of  the  right  kidney,  transverse  section,  a.  External 
oblique  muscle,  h.  Peritona'uni.  c.  Transversalis  muscle,  d.  Internal  oblique  mus- 
cle, e.  Peritona'um.  /.  Latissimus  dorsi  muscle,  g.  Anterior  layer  of  lumbar  fas- 
cia, h.  Middle  layer  of  lumbar  fascia  lying  above  transversalis  fascia,  i.  Posterior 
layer  of  lumbar  fascia. 

the  lumbar  aponeurosis  connected  with  the  internal  oblique  and  transversalis 
muscles  down  to  the  quadratus  lumborum  ;  ligature  the  lumbar  arteries  ;  push 
aside  or  divide,  as  necessary,  the  outer  border  of  the  quadratus  lumborum 
muscle ;  cut  through  the  anterior  lamella  of  the  lumbar  fascia  and  expose  the 
fascia  transversalis  (Fig.  1034) ;  divide  this  fascia,  and  thus  expose  to  view 
the  fatty  capsule  of  the  kidney ;  draw  apart  the  borders  of  all  the  divided 


Flu.  103").— Instruments  cm[)loyed  in  operations  on  llie  kidney. 
a.  Retractor,   exploring   needle,   probe,  grooved   director,   and  ^enotome,   employed   in 


forceps,  long-handled  scissors,  large  drainage  tube,  a  spatula,  and  a  uterine  dilator 
should  be  provided.  go- 


828 


OPERATIVE  SURGERY. 


Fig.  1036. — The  exposure  of  the  kidney.  Incision 
at  outer  border  of  erector  spiniB  muscle.  Pa- 
tient in  Simon's  position. 


tissues,  causing  the  fatty  capsule  to  project  iuto  tlie  wound  under  pressure 
directed  upward  and  backward  by  the  hand  of  an  assistant  applied  to  the 
abdomen  in  front ;  insert  the  fingers  into  the  wound  beneath  tlie  fatty  cap- 
sule and  draw  it  and  the  kidney  farther  outward ;  open  the  fatty  capsule  in 
the  long  axis  of  the  kidney ;  seize  the  borders  of  the  divided  capsule  and 

draw  them  with  the  kidney  still 
farther  outward,  thus  causing 
the  capsule  to  embrace  the  kid- 
ney snugly;  from  this  time  one 
of  several  plans  of  fixation  can 
be  practiced.  1.  Trim  away  the 
superabundant  fatty  capsule,  and 
sew  the  divided  borders  to  the 
deep  structures  of  the  wound 
with  kangaroo  tendon  or  chro- 
micized  catgut.  In  this  method 
the  borders  of  the  wound  are 
approximated  somewhat,  and  the  remaining  space  stuffed  with  gauze,  which 
is  removed  from  time  to  time,  with  the  idea  of  fixing  the  kidney  in  place 
by  means  of  the  cicatricial  attachments  resulting  from  the  closure  of  the 
wound  by  granulation.  This  method  can  not  be  commended  because  of 
tlie  low  rate  of  success.  2.  After  the  fatty  capsule  is  trimmed,  divide  the 
fibrous  capsule  longitudinally  at  the  outer  border  of  the  kidney  for  three  or 
four  inches  ;  strip  off  the  capsule  for  half  an  inch  at  either  side  of  the  entire 
length  of  the  incision  ;  pass  five  or  six  chromicized  catgut  or  kangaroo-ten- 
don sutures  at  either  side,  causing  them  to  include  the  reflected  part  of  the 
fibrous  capsule,  a  limited  portion  of  the  unreflected  part,  the  kidney  sub- 
stance for  half  an  inch,  and  the  border  of  the  fatty  capsule,  with  the  trans- 
versalis  fascia  and  the  other  deep  tissues  of  the  wound.  Three  or  four 
sutures  are  carried  from  side  to 


side  through  the  transversalis 
and  lumbar  fasciae  and  the  su- 
perimposed deep  tissues,  the 
stripped  fibrous  capsule,  the  un- 
stripped  near  to  its  attachment 
and  the  kidney  structure  for  an 
inch  or  so,  and  tied  after  approxi- 
mation of  the  borders  of  the 
main  wound  with  suture  so  as 
to  relieve  the  strain  on  the 
deeper  ones.  These  sutures  are 
drawn  only  suflficiently  firm  to 
approximate  and  hold  the  various  structures  in  position  while  union  takes 
place.  The  technique  of  fixation  is  variously  modified,  and  is  quite  too  ex- 
tended to  be  presented  in  detail.  It  is  sufficient,  as  it  seems  to  us,  to  indi- 
cate that  the  kidney  can  be  anchored  to  the  borders  of  the  abdominal  wound 
by  one  of  the  following  plans,  with  varying  results  (page  834)  (Delvoie) : 


Pig.  1037. — The  exposure  of  the  kidney.  Incision 
at  outer  border  of  erector  spin;e.  Patient  in 
Laiige's  position. 


Ul'EliATIuXS  OX    VISCKKA   CONNECTKI)   WITH    PKllITOX.KUM.     ?52l) 

(a)  Suture  of  the  fiitty  capsule  to  borders  of  woujid. 

(b)  Suture  of  the  fibrous  capsule. 

(c)  Suture  of  tiie  parcnciiynia  without  stripping  of  the  capsule. 

(d)  Suture  of  the  parenchyma  after  stripping  of  the  capsule. 

(e)  In  either  instance  the  kidney  should  be  pushed  into  the  wound  be- 
fore fixation. 

if)  Special  methods  of  practice. 

Senn's  Method. — Si'/m,  after  exposure  of  the  kidney  through  the  vertical 
incision,  divided  and   removed  the  fatty  and  scarified  the   fibrous  capsule 


Fig.    1038. — The   operation   of   nephropexy.  Senn's  method.      Showing  sling  of  gauze 

around  upper  end  of  kidney. 

freely  with  cambric  needles   held    by  forceps.     He  passed  underneath  the 
upper  extremity  of  the  kidney  a  strip  of  iodoform  gauze  twelve  inches  long 


Fig.  1039.— The  operation  of  nephropexy,  Senn's  method.     Showing  sling  of  gauze  and 

pad. 

and  two  inches  wide,  placing  a  gauze  pad  over  the  exposed  portion  of  the 
kidney  (Figs.  1038  and  1039),  and  carrying  a  sling  of  gauze  around  the  kid- 


830 


OPERATIVE   SURGERY. 


ney,  fastened  it  in  position  over  the  gauze  pad.  lie  introduced  two  sutures 
into  the  upper  angle  of  the  wound,  leaving  them  untied.  He  then  packed 
around  and  beneath  the  kidney  abundant  gauze,  and  placed  and  bound  in 
position  over  the  riglit  liypochondrium  a  pad  of  suflHcient  dimensions  to  re- 
enforce  the  gauze  supports. 

The  wound  was  redressed  in  three  days  and  tlie  secondary  sutures  tied. 
The  packing  beneath  the  kidney  was  removed  in  six  days  after  the  opera- 
tion, and  the  gauze  sling  in  eleven,  exposing  to  view  in  each  instance  freely 
granulating  surfaces,  which  were  maintained  in  contact  with  each  other  by 
means  of  adhesive  strips  carried  around  the  body,  and  which  at  the  same 
time  narrowed  the  external  wound.  In  this  operation  the  patients  should 
be  kept  in  the  recumbent  posture  until  the  adhesions  become  substantially 
organized.  The  claims  made  by  Senn  in  support  of  this  method  of  practice 
are  certainly  rational  and  prudent.  He  says  :  "  1.  An  extrarenal  support  of 
the  kidney  is  obtained.  2.  This  support  is  formed  by  union  of  the  fibrous 
capsule  of  the  kidney  with  the  pararenal  connective  tissue ;  hence  no  inter- 
ference with  the  kidney  itself.  3.  The  gauze  sling  draws  the  lower  pole  of 
the  kidney  in  an  outward  direction,  j^lacing  the  axis  of  the  kidney  at  an 
oblique  angle.  This  position  secures  support  from  the  parietal  wall  at  the 
lower  angle  of  the  wound,  and  favors  correction  of  flexion  of  the  ureter,  pro- 
vided it  be  present."  If  the  kidney  is  not 
held  in  proper  position  by  the  gauze  sling, 
as  illustrated,  it  should  be  carried  around 
the  lower  instead  of  the  upper  part  of  the 
kidney. 

Dearer  removes  the  fatty  capsule  en- 
tirely from  the  posterior  surface  and  to 
the  hilum  from  the  anterior.  He  jjasses 
gauze  beneath  the  upper  pole  of  the  kid- 
ney and  below  the  lower,  allowing  it  to 
remain  in  place  for  a  week  or  ten  days. 
Gauze  is  packed  around  the  kidney  and 
the  hypogastric  compress  employed  as  in 
the  preceding  instance.  Usually  the  wound 
heals  completely  in  four  or  five  weeks. 

Morris's  Method. — Henry  Morris  fixes 
the  kidney  in  the  wound  by  means  of 
three  silk  sutures  passed  through  the 
fibrous  capsule  and  kidney  substance  and 
the  borders  of  the  transverse  fascia  and 
aponeurosis  of  the  transversalis  muscle 
and  tied,  as  indicated  in  the  illustration 
(Fig.  1040).  The  wound  is  closed  at 
once  and  the  patient  kept  quiet  in  bed 
for  three  or  four  weeks.  Morris  has  practiced  this  plan  satisfactorily  for 
many  years,  and  consequently  commends  it  highly.  Strict  asepsis  should 
be  practiced,  otherwise  the  silk  sutures  will  become  troublesome. 


Fig 


1040. — The   operation   of    nephro- 
pexy, Morris's  method. 


OPKRATIONS  ().\    VlsrKRA   CONNECT?]!)    WITH    rKKlTuNyEUM.     831 


Tttuffer,  objectiii*,'  to  tlie  introduction  of  sutures  into  the  kidney,  "  because 
of  their  ill  elTects,"  advised  limited  decortication,  with  the  view  of  securing 
union  of  the  exposed  kidney  structure  to  the  abdominal  wound,  aided  by 
stitching  the  retlected  flaps  to  the  fascial  and  aponeurotic  tissues.  Modifica- 
tions in  the  size,  extent,  shape,  and  attacliments  of  the  fiaps  have  been  prac- 
ticed by  dilTerent  operators,  but  as  yet  a  decided  opinion  regarding  their 
comparative  worth  can  not  be  expressed. 

VuUiet,  after  exposing  and  lifting  the  kidney  in  tlie  usual  manner,  raises, 
through  a  short  vertical  incision  of  the  skin  and  fascia,  made  parallel  with 
the  spinous  ])roccss  of  the  first  lumbar  verte- 
bra, a  slip  of  the  tendon  of  the  erector  spina?, 
about  ten  inches  long  and  a  quarter  of  an 
inch  wide,  which  is  then  divided  above,  pulled 
out  through  the  jn-imary  wound,  and  left 
attached  below.  The  slip  is  then  carried 
through  the  muscle,  caused  to  underrun  the 
fibrous  capsule  of  the  kidney,  thence  is  passed 
backward  and  attached  to  the  muscle  above 
(Fig.  10-41).  Morn's  divides  the  slip  into 
upper  and  lower  portions,  and  passes  one  be- 
neath the  capsule,  tying  the  end  to  the  re- 
maining part. 

Franks,  noting  the  fact  that  the  kidney, 
when  liardened  in  position,  is  grooved  by  the 
twelfth  rib,  advises  anchoring  the  organ  to 
that  bone.  Therefore  the  capsule  is  divided 
and  reflected  briefly  at  the  place  on  the  sur- 
face wliere  it  is  proposed  to  pass  the  sutures. 
The  flaps  and  the  exposed  kidney  substance 
are  then  sutured  to  the  twelfth  rib  with  catgut. 
for  six  weeks. 

After  fixation  is  comjileted  the  sutures  are  cut  short,  the  deep  tissues  of 
the  wound  united  with  buried  catgut  sutures  and  the  superficial  closed  with 
silkworm  gut,  leaving,  if  desired,  proper  space  for  the  introduction  of  deep 
drainage.  The  usual  aseptic  dressings  are  ai)plied  to  the  wound,  and  a  firm 
compress  is  so  placed  in  front  as  to  maintain  the  kidney  in  proper  relation 
with  the  wound  on  apjilication  of  the  abdominal  binder. 

The  incision  for  reaching  the  kidney  in  this  operation  is  obliquely  placed 
by  many  surgeons  (Fig.  1012,  a),  the  obliquity  being  modified  by  the  need  for 
room.  The  oblique  incision  as  commonly  practiced  is  begun  an  inch  below 
the  twelfth  rib  at  the  outer  border  of  the  erector  spins,  and  is  carried 
obliquely  downward  and  forward  so  as  to  expose  the  anterior  border  of  the 
latissimus  dorsi,  and  the  posterior  border  of  the  external  oblique.  It  will  be 
seen  that  the  lumbar  aponeurosis  is  divided  farther  outward  in  this  incision 
than  in  the  vertical  one,  and  that  the  quadratus  lumborum  is  I'eached  nearer 
to  its  outer  border  (Figs.  1033  and  1013).  In  other  respects  no  practical 
difference  exists.     In  stout  patients  it  may  be  advisable  to  make  a  T-shaped 


Fig.  1041. — The  operation  of  ne- 
phropexy, Vulliet's  method. 

The  patient  is  kept  in  bed 


832 


OPERATIVE   SURGERY. 


incision,  to  afford  more  looni  and  better  observation.  The  horizontal  part 
of  this  incision  should  be  securely  closed  at  once,  irrespective  of  the  treat- 
ment of  the  remaining  portion. 

Hie  kidney  can  he  readily  exposed  for  diagnostic  and  otlier  purposes 
Avithout  dividing  the  muscles,  nerves,  or  vessels  by  means  of  the  "gridiron" 

manner     of    dissection 
employed  in   operation 
U         ^^^''"""^         *^B&--^     '^-^^^^^^^         ^^''    appendicitis.      Be- 
r  ^— «ssw<*^-  X  ""^^  ''~''3m^^^^^^^^^^IZ^~"^^ss       gin  the  incision  at  the 

inner  side  of  the  an- 
terior sujierior  s^^ine  of 
the  ilium,  and  carry  it 
obliquely  backward  and 
upward  toward  the  tip 
of  the  last  rib ;  split 
correspondingly  the 
fibers  and  aponeuroses 
of  the  external  oblique 
muscle,  and  draw  the 
borders  well  apart ;  split 
the  fibers  of  the  internal 
oblique  in  a  line  extend- 
ing between  the  ninth 
costal  cartilage  and  the 
posterior  superior  spi- 
nous process  of  the 
ilium,  and  retract  the 
borders,  thus  exposing 
the  fibers  of  the  trans- 
versalis  muscle ;  split 
and  draw  apart  the  fibers 
of  the  transversalis,  in- 
cise the  transversalis  fas- 
cia, exposing  the  sub- 
serous tissue  and  peri- 
renal fat ;  pass  the  fin- 
gers through  the  fat,  expose  and  raise  the  kidney  into  the  wound,  and 
anchor  it. 

Rob&on  commends  this  method  of  approach  as  being  useful  for  divers 
purposes  directed  to  the  kidney.  Time  in  operation  is  saved,  no  blood  is 
lost,  rapid  and  secure  repair  follows,  and  the  procedure  does  not  incur 
special  danger  nor  assume  the  lay  significance  of  free  incision. 

The  Precautions. — Carefully  note  the  presence  of  the  twelfth  rib,  and  as 
carefully  approach  the  upper  end  of  the  kidney  in  operation,  fearing  involve- 
ment of  the  pleural  and  peritoneal  cavities.  Eecognition  of  the  anterior 
lamella  of  the  lumbar  fascia  and  of  the  fascia  transversalis  (Figs.  1033  and 
103-i)  will  prevent  premature  search  for  the  kidney,  and  may  obviate  delay 


Fig.  1042. — The  linear  guides  for  operations  on  the  kidney. 
a.  Lines  for  incision  in  exploration  in  nethrotomy  and 
in  nephrolithotomy,  i.  Morris's  secondary  incision  in 
nephrectomy,  c.  Konig's  lurabo-abdominal  incision  in 
nephrectomy,  d.  Outline  of  iliac  crest.  /.  Eleventh 
rib.     e.  Twelfth  rib. 


OPERATIONS   ON    VISCERA   CONNKCTEI)    WITH    I'KRITON.EUM.     833 


and  even  defeiit  in  limling  it;  it  may  also  prevent  a  })recipitiite  and  perhaps 
unnecessary  involvement  of  the  peritoneal  cavity.  If  tlie  kidney  be  pushed 
too  far  upward  before  fixation,  the  downward  movement  of  the  liver,  with 
breathin<,',  will  hinder  {)ro{)er  union.  In  fact,  profound  inspiration  should 
be  interdicted  for  a  time  for  a  similar  reason.  A  freely  movable  and  a 
floating  kidney  should  be  approached  with  care  to  avoid  unnecessary  or 
unexpected  invasion  of  the  ])eritoneal  cavity.  If  the  fatty  capsule  is  thin, 
a  mesouephron  is  present,  and  involvement  of  the  peritoneal  cavity  by  tear- 
ing of  the  peritona?um  is  liable  to  happen,  especially  if  undue  vigor  is  used 
in  traction  or  other  manipulations.  These  tears  should  be  closed  at  once  by 
sewing  or  ligature,  depending  upon  the  size  and  situation. 

llie  Remarks. — Deep  drainage  should  be  employed  when  infection  of 
the  wound  is  suspected.  Deep  drainage  is  advised  by  some  surgeons  in  all 
instances  on  account  of  the  irritating  effect  on  the  tissues  of  its  presence, 
thereby  securing  firmer  union.  However,  this  desideratum  may  be  reached 
instead  by  a  free  scratching  of  tlie  tissues  before  closure  of  the  wound.     The 


sutures  involving  the  kid- 
ney structure  are  em- 
ployed for  the  purpose 
of  approximation,  not  of 
union  of  the  included 
structures,  for  if  drawn 
tightly  the  kidney  tissue 
is  promptly  cut  through. 
The  removal  of  the  pos- 
terior part  of  the  fatty 
capsule  is  advised  by  sonn, 
in  order  to  place  the  sub- 
jacent part  of  the  kidney 
directly  in  contact  with 
muscular  tissue.  Needles 
with  sharp  borders  and 
silkworm  gut  ought  not 
to  be  introduced  into  the 
kidney.  The  deeper  dis- 
sections are  conducted 
more  safely  by  means  of 
blunt  scissors.  Edeholils 
secures  ready  access  to  the 
kidney  by  placing  between 
the  belly  of  the  patient 
and  the  table  an  air-dis- 
tended rubber  cylinder 
nine  inches  in  diameter. 
After  division  of  the  fatty  capsule  the  patient  is  pulled  down  so  that  the 
chest  rests  on  the  rubber  cushion,  causing  the  respiratory  movements  of 
the  diaphragm  to  force  the  kidney  through  the  opening. 


Fi( 


.  1043. — The  anatomy  of  incisions  in  operations  on  the 
kidney.  A.  Lines  of  incisions  in  exploration  of  kid- 
ney in  nephropexy,  nephrectomy,  and  nephrolithoto- 
my. B.  Morris's  secondary  incision  in  nephrectomy. 
C'.  Konig's  lumbo-ahdominal  incision  in  nephrecto- 
my, d.  Transversalis  muscle,  e.  Internal  oblique 
miiscle.  f.  External  oblique  muscle,  g.  Intercostal 
nuiscles.  "/(.  Crest  of  ilium.  /.  Intercostal  nerve  and 
artery,  j.  Twelfth  dor.sal  nerve  and  lumbar  artery,  k. 
Fascia  lumborum.  erector  spina^  beneath.  /.  Serratus 
posticus  major  muscle.     /«.  Latissimus  dorsi  muscle. 


834 


OPERATIVE  SURGERY. 


The  after-treatment  consists  in  keeping  tlie  patient  quiet  in  the  recum- 
bent posture  for  three  or  four  weeks.  The  drainage  tube  may  be  retained 
for  some  time  with  the  view  of  stimuhiting  firm  rej^air.  The  contents  of  the 
bowels  are  kept  in  a  soluble  condition.  The  wearing  of  a  body  band  and 
the  avoiding  of  severe  strain  should  be  carefully  practiced  for  some  months. 

The  Results. — The  results  are  modified  very  largely,  indeed,  by  the  plan 
of  procedure  practiced  by  the  surgeon.  The  following  statistics  of  Delvoie, 
relating  to  two  hundred  and  fifteen  cases,  are  exceedingly  instructive,  and 
do  much  to  settle  the  best  methods  of  procedure  : 


Suture  of  the  fatty  capsule. . . 

Suture  of  the  fibrous  capsule. 

Suture  of  tlie  parenchyma  with- 
out stripping  of  the  capsule. 

Suture  of  the  parenchyma  after 
stripping  the  capsule 

Special  methods 

Operative  procedures  of  uncertain 
character 


No.  cases. 

Cures. 

Ini- 
pi'uved. 

Unsuc- 
cessful. 

Relapse. 

14 
24 

110 

10 
10 

47 

4 
10 

75 

9 
5 

32 

3 
3 

14 

0 
5 

5 

2 
4 

11 

1 
0 

7 

5 
5 

8 

0 
0 

2 

215 

135 

30 

25 

20 

Deaths. 

0 
2 


The  general  death  rate  is  from  2  to  4  per  cent  when  the  operation  is 
practiced  under  favorable  auspices.  According  to  Albarran,  in  3T4  cases  7 
died  within  four  months  of  operation,  of  which  deaths  4  could  be  attributed 
properly  to  the  operative  procedure  alone.  In  88  per  cent  of  these  cases  pain 
was  cured ;  in  14  per  cent  nervous  symptoms  were  partially  cured,  but  in  3G 
per  cent  no  benefit  was  experienced  in  this  regard.  Edehohls  reports  1  death 
in  50  cases  with  but  2  relapses  in  six  years.  Morris  reports  57  cases  of  his 
own,  with  57  recoveries. 

Nephrolithotomy. — Xephrolithotomy  is  the  operation  of  incision  of  the 
kidney  for  the  removal  of  stone. 

The  special  instruments  needed  are  retractors,  spatulas,  a  long  needle 
with  a  handle,  probes,  small  scoops,  small  lithotrity  forceps,  dressing  and 
polypus  and  lithotomy  forceps  (Fig.  1035,  a,j,f,  h). 

The  kidney  can  be  exposed  by  means  of  a  lumbar  or  an  abdominal  in- 
cision (Figs.  1042,  1043,  and  0r;3)"; 

The  Lumbar  Method  of  Operation.— After  thorougli  cleansing  of  the  colon, 
and  employment  of  local  antiseptic  measures,  place  the  patient  on  the  sound 
side  and  expose  the  kidney  (Figs.  1042  and  1043,  a)  as  in  nephropexy  (page 
826).  After  division  of  the  transversalis  fascia  expose  the  fatty  capsule  freely 
by  wide  retraction  of  the  borders  of  the  divided  tissues ;  expose  the  kidney  by 
dividing  and  pushing  aside  the  fatty  capsule  ;  press  the  kidney  into  the  wound 
from  in  front;  introduce  the  finger  between  the  fatty  capsule  and  the  kidney 
at  the  posterior  surface,  and  feel  for  the  presence  of  stone  while  counter  pres- 
sure is  made  in  front ;  examine  the  anterior  surface,  using  firm  pressure  for  the 
purpose;  thrust  the  exploring  needle  (Fig.  1035,  a)  into  raised  or  indurated 
areas  of  the  kidney  to  determine  the  presence  of  stone.     If  nothing  unusual 


OPERATIONS   OX    VISCKRA    CONNPXTKI)    WITH    I'KRITON.KUM.     835 

be  noted  on  palp.ition,  support  the  kidney  lirrnly  with  the  hand  ;  introduce 
the  exploring  needle  at  tiie  external  l)order  between  the  ends  of  the  organ, 
passing  it  toward  the  hiluni,  ten  or  twelve  times  if  necessary.  Tlie  pelvis  of 
the  kidney  can  be  readily  explored  by  means  of  a  small  sound  (Fig.  103'),  p) 
passed  into  it  through  a  narrow  incision  made  into  the  calix  at  the  lower  end 
of  tlie  organ  (Ijloyd).  Tiie  metal  bouijie  a  houle  (Fig.  '[')i)'i)  is  the  better 
searcher  for  this  purpose  (Clarke).  Failing  with  these  means  to  find  a  stone, 
make  an  incision  at  the  external  border  of  tiie  kidney  (Morris),  or  through 
the  thinner  part  near  the  })elvis  (Jacobson),  or  tiirough  the  wall  of  the  pelvis 
itself  (Thornton),  through  either  of  which  examination  of  the  pelvis  can  be 
made  by  the  finger  or  an  instrument.  The  first  incision  is  regarded  the  best, 
since  the  wound  heals  more  promptly,  and  therefore  is  less  liable  to  form  a 
fistula  (page  839).  The  situation,  size,  shape,  and  compactness  of  the  stone 
will  determine  the  freedom  of  removal.  If  a  stone  be  located  in  the  cor- 
tical tissue,  it  should  be  removed  through  an  opening  made  directly  down 
upon  it.  If  it  be  in  the  pelvis  of  the  kidney  or  at  the  mouth  of  the  ureter, 
it  should  be  removed  through  the  channel  that  leads  to  the  discovery,  if 
practicable,  otherwise  tiirough  a  short  incision  into  the  pelvis  at  the  posterior 
wall,  made  cautiously  with  a  sharp  knife.  Limited  incision  with  a  narrow 
tenotome  (Fig.  1035,  a),  followed  by  digital  or  instrumental  dilatation  and 
rupture,  affords  the  safest  means  of  gaining  access  to  a  stone.  The  stretched 
and  ruptured  tissue  bleeds  comparatively  little  and  heals  promptly,  and  the 
presence  of  the  finger  in  the  opening  reduces  the  amount  of  haemorrhage  to 
a  minimum.  The  stone  is  removed  with  the  finger,  aided  by  scoops,  forceps 
(Fig.  1035,  /,  h,j),  etc.  If  it  be  large,  hard,  or  irregular,  it  should  be  broken 
and  removed  piecemeal,  remembering  that  it  is  better  to  spoil  a  good  speci- 
men than  to  damage  a  kidney  in  endeavoring  to  preserve  the  specimen. 
Stones  surrounded  by  suppurating  processes  are  more  easily  removed  than 
those  that  are  not,  and  the  removal  should  be  attended  with  antiseptic 
douching.  The  presence  of  stone  at  the  opening  of  the  ureter  or  farther 
along  in  the  tube  should  be  carefully  determined  by  the  finger  and  probe. 
The  removal  of  a  stone  from  the  opening  of  the  ureter  requires  skill  and 
patience  to  secure  the  best  outcome.  The  parts  should  be  thoroughly 
cleansed  after  removal  of  the  stone,  especially  if  purulent  processes  have 
been  present.  In  the  absence  of  infective  kidney  changes  the  incisions  of 
the  kidney  can  be  closed  with  fine  catgut  and  the  abdominal  wound  closed 
completely  in  the  usual  manner ;  in  their  presence,  however,  closure  of  the 
kidney  wounds  should  be  omitted.  Where  infection  exists  the  introduction 
of  a  rubber  drainage  tube  behind  the  kidney,  the  closure  of  the  soft  parts 
around  it  by  sewing,  and  the  application  of  the  usual  aseptic  dressings  com- 
plete this  stage.  If  the  perforated  end  of  the  tube  be  fixed  firmly  in  the 
wound  by  sewing,  and  the  outer  part  be  introduced  into  a  convenient  bottle, 
the  urine  may  be  entirely  collected  for  a  time,  whereby  soiling  of  the  tissues 
will  be  avoided. 

The  Remarks. — The  fatty  capsule  may  be  adherent,  tough,  or  dense,  thus 
interfering  with  the  manipulation  of  the  kidney.     The  pelvis  can  be  exam- 
ined posteriorly  to   advantage  if  the    kidney  be  turned   upward   (Lange). 
59 


336  OPERATIVE   SURGERY. 

Wounds  of  the  pelvis  of  tlie  kidney  wlien  carefully,  sewed  often  heal  quite  as 
promptly  as  the  denser  structure.  In  the  removal  of  stone  through  incision 
of  the  renal  pelvis,  exploration  of  the  cavity  with  the  finger  should  be  prac- 
ticed if  the  size  of  the  opening  will  permit ;  if  not,  the  opening  may  be  en- 
larged or  the  pelvis  invaginated.  If  sutures  are  not  to  be  employed  to  close 
the  wound  of  the  pelvis,  it  is  better  that  the  wound  be  made  at  the  anterior 
than  at  the  posterior  aspect,  as  then,  with  the  patient  lying  on  the  back,  the 
urine  is  less  liable  to  escape  (Morris).  Jlorris  does  not  regard  the  presence 
of  suppuration  in  the  pelvis  as  a  sufficient  reason  for  the  omission  of  sutures 
for  the  purpose  of  securing  union.  Fenger,  we  believe  wisely,  holds  that  the 
presence  of  stone  in  the  pelvis  is  an  assurance  of  sepsis  there,  and  warns 
against  the  employment  of  sutures  with  the  view  of  securing  primary  union. 
Free  incisions  of  the  kidney  bleed  copiously  though  not  persistently,  and  the 
flow  can  be  quite  readily  controlled  by  sponge  or  gauze  packing  with  or 
without  hot  douching.  If  suppurative  processes  have  been  present  and 
haemorrhage  is  severe,  especially  in  a  feeble  patient,  a  small  drainage  tube 
should  be  introduced  into  the  kidney  and  the  surrounding  cavity  packed 
with  iodoform  gauze.  The  tube  sometimes  can  be  introduced  into  the 
kidney  in  other  suppurative  cases  if  extensive  tissue  changes  be  present.  In 
a  stout  patient,  or  in  the  case  of  a  large  or  a  very  high  kidney,  a  long,  deep, 
perhaps  irregular  and  even  high  incision  should  be  made  to  meet  the  require- 
ments of  the  operation.  The  X  ray  should  be  employed  for  diagnostic  pur- 
poses before  operation  is  attempted. 

The  Precautions. — Incision  of  the  kidney  should  be  made  vertically 
toward  the  hilum  to  avoid  unnecessary  division  of  the  cortical  structure. 
The  exploring  needle  should  be  about  two  inches  and  a  half  in  length  ;  if 
too  long,  or  if  handled  carelessly,  it  may  puncture  important  vessels  at  the 
hilum.  In  this  connection  it  is  wise  to  remember  that  the  normal  kidney 
is  from  two  to  two  and  a  half  inches  in  width  and  rather  more  than  an  inch 
in  thickness.  Keep  in  mind  the  deviations  of  the  pleura  and  its  relations  to 
the  twelfth  rib  (page  824)  so  as  to  avoid  opening  the  pleural  cavity.  Small 
calculi  are  apt  to  escape  notice  in  every  plan  of  search.  Tuberculous  de- 
posits, small  abscesses,  isolated  indurations,  etc.,  may  be  mistaken  for  stone 
on  palpation.  If  the  ureter  be  pervious,  colored  fluid  can  be  injected  through 
it  into  the  bladder  and  the  fact  established  by  examination  of  the  urine.  If 
the  ureter  be  washed  out  thoroughly  with  water,  then  plugged  above,  the 
bladder  washed,  and  the  urine  drawn  some  time  thereafter  and  tested,  the 
condition  of  the  opposite  kidney  can  be  determined  (Tiffany).  The  ureter 
should  be  explored  to  determine  its  patency  in  all  instances  of  stone  in  the 
kidney,  and  in  those  cases  in  which  this  can  not  be  accomplished  through 
the  cortical  incision  a  minute  longitudinal  incision,  made  at  the  back  of  the 
pelvis  with  the  point  of  a  scalpel,  should  be  employed  for  the  purpose,  and 
thereafter  promptly  closed  by  sewing.  In  opening  into  the  pelvis  at  this 
situation  the  renal  vein,  or  a  branch  of  it,  may  be  mistaken  for  the  pelvis, 
with  obvious  result.  The  application  of  a  circular  ligature  to  the  opening 
will  readily  arrest  the  bleeding.  If  a  doubt  arise  regarding  the  identity  of 
these  structures,  forward  pressure  on  the  ureter  will  cause  the  vein  to  col- 


OPKKATIOXS   0\   VTSrERA    TONNRCTRD   WITfl    I'KKI'lf  >X.EU:\r.     837 


lapse,  Hiul  removal  of  the  pressure  will  restore  the  circulation.  The  probing 
of  old  kidney  sinuses  incautiously  may  lead  to  puncture  of  the  colon.  Also 
the  peritomeum  may  be  ruptured  or  j)unctured  unavoidably,  and  from  care- 
less manipuhition.  In  either  instance  tlie  seat  of  the  injury  should  be  thor- 
oughly cleansed  and  promptly  closed  by  sewing,  and  especially  is  this  course 
demanded  if  infecting  agents  are  present.  When  douching  fluids  fail  to 
return  wholly  or  in  part,  the  possibility  of  their  escape  through  a  tear  into 
the  peritoneal  cavity  should  be  entertained  as  not  uidikely,  and  abdominal 
section  and  thorough  cleansing  may  be  demanded.  The  adherence  in  the 
manipulations  as  closely  as  practicable  to  the  posterior  wall  of  the  abdomen, 
and  in  any  event  the  approaching  with  care  to  the  anterior  surface  of  the 
kidney,  will  lessen  the  danger  of  invasion  of  the  peritoneal  cavity. 

Morris's  Method  of  Exploration. — Morris  approaches  the  kidney  and 
ureter  through  an  oblique  incision  beginning  in  front  of  and  an  inch  above 
the  anterior  superior  spine  of  the  ilium,  and  extending  obliquely  outward 
and  backward  to  a  point  corresponding  to  the  outer  border  of  the  erector 
spinte  muscle  and  an  inch  below  the  twelfth  rib  (Fig.  1044).  The  length 
and  direction  are  modified  accord- 
ing to  requirements.  If  greater 
room  be  needed  above,  the  inci- 
sion is  extended  back  over  the 
erector  spinas  {c,  d),  perhaps  di- 
viding its  outer  border,  or  is  car- 
ried upward  vertically  or  oblique- 
ly over  the  outer  surface  of  the 
twelfth  rib,  to  facilitate  manipu- 
lation and  subsequent  removal  of 
the  bone  when  necessary.  When 
either  examination  of  the  ureter 
or  of  the  lower  part  of  the  kidney, 
or  possibly  the  control  of  deep 
haemorrhage,  is  demanded,  the  in- 
cision is  extended  farther  down- 
ward in  a  curved  manner  toward 
Poupart's  ligament,  then  inw^ard, 
parallel  to  and  an  inch  above  it, 
as  circumstances  suggest  (a,  h). 
The  bleeding  points  are  caught 
and  tied  as  the  incision  is  deep- 
ened. Approach  carefully  and 
divide  at  first  a  limited  portion  of 
the  transversalis  fascia  cautiously,  avoiding  the  colon,  which  frequently 
bulges  into  the  wound ;  draw  aside  the  borders  of  the  wound  with  broad 
retractors,  being  sure  to  include  the  colon;  pass  the  forefinger  behind  the 
loose  covering  of  the  kidney  and  press  the  structures  forward  ;  seize  and 
drag  into  the  wound  a  portion  of  this  covering  with  two  pairs  of  long 
forceps,  and  snip  the  tissue  between  them  with  scissors ;  note  the  prompt 


Fig.  1044. — A  Hue  of  approach  to  the  kidney 
and  ureter,  ]Morris"s  method,  a,  d.  Primary 
incision,     a,  b,  and  c,  d.  Secondary  incisions. 


838  OPP^RATIVE   SURGERY. 

appearance  of  the  fine  yellow  fat  which  closely  invests  the  kidney;  j)ass 
into  the  opening  made  by  the  scissors  first  one  then  the  other  index  fin- 
ger ;  draw  aside  and  carefully  detach  the  fatty  tissue  from  the  posterior 
surface  of  the  kidney  with  the  fingers ;  palpate  the  pelvis  and  the  upper 
part  of  the  ureter  to  detect  the  presence  of  calculi,  and  prevent  with  the 
finger  the  entrance,  if  possible,  of  any  calculus  into  the  ureter  that  might 
occur  as  a  result  of  the  further  manipulation  of  the  organ  ;  free  the  kidney 
at  all  aspects  from  its  fatty  environment  and  raise  it,  if  practicable,  freely 
out  of  the  wound ;  seize  the  organ  with  the  thumb  and  finger  so  as  to  steady 
it,  and  compress  the  pedicle  to  control  bleeding  while  making  an  incision  into 
the  kidney  along  the  convex  border;  introduce  through  the  incision  into  the 
kidney  the  right  index  finger,  and  examine  carefully  the  interior  for  stone ; 
remove  through  the  opening  by  means  of  forceps  any  calculus  that  may  be 
discovered,  cautiously  enlarging  the  opening  by  stretching  or  cutting,  so  as 
to  permit  the  escape  without  needless  laceration  of  the  tissue ;  press  upward, 
if  possible,  into  the  pelvis  any  stone  lodged  in  the  upper  end  of  the  ureter, 
and  remove  it  through  an  incision  radiating  from  the  hilum  down  upon  any 
other  calculus  that  may  be  present  in  the  sound  kidney  ;  make  the  incision  in 
pouched  and  atrophied  portions  of  the  kidney,  extending  from  the  primary 
opening  in  the  direction  best  intended  to  facilitate  a  prompt  and  secure 
removal  of  either  simple,  multiple,  or  branching  calculi ;  explore  for  a  second 
calculus  through  the  original  incision,  or  through  another,  and  remove 
through  the  one  best  adapted  for  the  purpose ;  cleanse  the  kidney  thoroughly 
if  infecting  products  be  present,  and  introduce  a  drainage  tube  into  the  wound 
outside,  but  not  within  the  kidney ;  unite  the  borders  of  the  kidney  wound 
with  sutures  if  the  tissues  are  sound  ;  if  not,  sutures  may  be  employed,  for  the 
purposes  of  restraint,  but  not  with  the  expectation  of  union.  Morris  closes 
the  parietal  wound  by  suture  of  the  borders  en  inasse,  therefore  without  the 
aid  of  buried  sutures. 

The  Eemarks. — A  fixed  and  rational  plan  of  exploration  of  the  kidney 
and  ureter  should  be  a  part  of  the  operative  store  of  those  -who  engage  in  the 
treatment  of  kidney  disease. 

The  Abdominal  Explorative  Method  of  Operation  (combined  method). — In 
this  method  the  explorative  incision  is  nuule  in  front,  while  the  stone  is  removed 
through  another,  and  possibly  shorter,  incision  made  in  the  lumbar  region. 

The  Operation. — Open  the  abdomen  in  the  semilunar  line  from  the  mar- 
gin of  the  ribs  to  a  point  opposite  the  umbilicus  (Langenbiich)  (Fig.  963) ; 
introduce  the  hand  and  examine  both  kidneys  and  ureters  carefully  for  stone  ; 
press  the  organ  into  place  firmly  and  push  the  colon  inward  if  stone  be  found 
in  the  kidney  ;  make  an  incision  in  the  lumbar  region  down  upon  the  kidney 
as  in  the  preceding  instance;  expose  and  remove  the  stone  through  the  loin 
and  treat  the  case  as  before  detailed. 

The  Remarks. —  The  ascertainment  of  the  condition  of  both  kidneys  and 
ureters,  and  the  avoidance  of  injury  to  contiguous  vessels  are  the  chief  advan- 
tages of  this  method.  However,  the  use  of  the  cystoscope  (page  1159)  may 
enable  one  to  determine  the  condition  of  Ijoth  kidneys  by  noting  the  charac- 
teristics of  their  respective  discharges  into  the  bladder.    And,  too,  catheterism 


OPERATIONS   ON    VISCKKA   CONNECTED    WITH    I'KKITON^UM.     839 

of  the  ureters  (page  SS'Z  el  .s(v/.),espeeially  in  the  feniule,  nuiy  detect  the  pres- 
ence of  stone  in  the  kidney.  If  a  distended  colon  obstructs  tlie  way,  push 
it  aside  and  (^online  with  sponges.  The  drainage  tulje  should  be  shortened 
from  time  to  time  as  the  wound  closes,  and  not  finally  removed  until  unaided 
drainage  is  assured.  If  the  patient  be  stout,  or  the  abdominal  walls  rigid,  or 
the  kidney  and  tlie  contiguous  tissues  indurated,  the  diMiculties  of  the  ojjcra- 
tion  arc  correspondingly  increased.  A  large  branching,  hard  calculus,  or  a 
phosphatic  one  that  crumbles  readily  allowing  some  portions  to  escape  obser- 
vation, complicates  the  final  recovery.  If  the  kidney  has  been  much  disturbed 
by  the  manijiulations,  and  especially  if  a  subsequent  examination  be  regarded 
as  })robable,  and  the  condition  of  the  other  kidney  permitting,  nephropexy 
should  be  performed. 

The  After-treatment. — The  abdominal  wound  is  closed  at  once  in  the 
usual  manner.  To  the  lumbar  wound  in  either  method  the  local  treatment 
is  chiefly  addressed.  Cleanliness,  proper  drainage,  the  prevention  of  irrita- 
tion of  the  skin  by  the  escaping  fluids,  abundant  and  frequently  applied 
absorbent  dressings,  constitute  the  principal  measures  in  the  treatment  of 
these  wounds. 

The  Results. — In  nephrolithotomy  the  general  death  rate  is  about  14 
per  cent,  in  non-suppurative  cases  from  2  to  5  per  cent,  in  the  suppurative 
43  per  cent.  Morris  reports  34  personal  operations  with  33  recoveries. 
Raiisohoff  reports  44  operations  with  failure  to  find  stone,  in  none  of  which 
did  death  occur,  and  many  were  cured.  Also  that  sinus  follows  pelvic  in- 
cisions of  the  kidney  about  seven  times  more  frequently  than  when  the 
incision  is  made  at  the  outer  border. 

Neplirotoiny.— Nephrotomy  consists  in  cutting  into  the  kidney  a  greater 
or  lesser  depth  for  the  removal  of  calculi,  tumors,  fluid  accumulation,  and 
for  the  relief  of  nephralgia,  etc. 

The  Operation. — Place  the  patient  as  for  nephrolithotomy  ;  make  the 
lumbar  incision  (Figs.  1042,  1043)  as  in  this  operation  in  the  absence  of 
redness  and  fluctuation.  If  either  be  present,  make  the  incision  at  the  site 
of  the  most  pronounced  redness  or  fluctuation.  Expose  the  kidney  and 
explore  suspicious  points  found  at  any  aspect  of  the  organ  with  a  grooved 
needle  ;  incise  with  a  knife  and  remove  with  the  finger  or  a  scoop  pus  col- 
lections, examining  carefully  for  calculi  and  communicating  abscesses ;  flush 
the  kidney  with  a  hot  antiseptic  solution  ;  introduce  a  rubber  drainage  tube 
as  far  as,  and  sometimes  into  the  kidney,  if  extensive  disease  be  present ;  close 
the  external  opening  around  the  tube  by  sewing  and  fasten  the  tube  in  place ; 
wash  the  wound  through  the  tube  frequently  with  antiseptic  fluid  and  shorten 
the  tube  as  healing  progresses.  If  the  operation  be  for  hydatid  or  other  cysts, 
hydronephrosis,  pyonephrosis,  etc.,  the  incision  is  made  at  the  usual  site, 
and,  as  the  dissection  advances,  notable  thinning  of  the  respective  structures 
is  seen  to  have  taken  place,  the  fatty  portion  particularly  being  much  con- 
densed and  thinned,  and  perhaps  adherent  in  places  to  the  kidney.  Espe- 
cially is  this  true  if  much  distention  has  occurred.  If  a  cyst  be  present, 
expose  the  sac,  make  a  small  incision  into  it  with  a  knife  or  empty  it  by 
aspiration  ;  grasp  with  forceps  and  draw  outward  the  relaxing  borders  of  the 


84,0  OPERATIVE   SURGERY. 

sac  and  sew  them  to  tlie  deep  tissues  of  the  abdominal  wound  or,  if  possible, 
to  the  cutaneous  borders ;  examine  the  cyst  cavity  with  the  finger  for  con- 
tiguous cysts;  introduce  a  large  drainage  tube  into  the  wound,  close  the 
borders  of  the  incision  around  it  by  sewing,  and  dress  the  wound  as  before. 
Cleanse  the  Avouud  through  the  tube  occasionally  and  apply  abundant  anti- 
septic dressing. 

If  pyonephrosis  or  hydronephrosis  be  encountered,  due  to  obstruction  of 
the  ureter,  the  obstruction  should  be  removed  if  practicable,  and  the  wound 
treated  as  in  the  presence  of  pus  from  other  causes.  Failing  in  the  removal 
of  the  obstruction  by  other  operative  methods,  either  a  permanent  fistula 
must  be  anticipated  or  the  kidney  removed  at  once. 

The  Precautions. — If  the  kidney  be  mobile,  careful  action  is  essential  or 
the  peritoneal  cavity  will  be  involved.  The  breaking  down  of  partitions 
between  contiguous  cavities  in  the  kidney  should  be  avoided,  if  possible,  as 
severe  bleeding  is  liable  to  occur  from  the  vessels  in  the  partitions,  especially 
in  tuberculous  and  suppurative  processes.  The  surface  of  the  kidney  should 
be  examined  carefully  after  evacuation  of  a  perinephritic  abscess  for  the 
presence  of  small  abscesses  or  other  circumscribed  disease  of  the  organ. 
Large  drainage  tubes  and  frequent  cleansing  are  required  in  suppurative 
kidney  changes  to  secure  cleanliness  and  avoid  sepsis.  Drainage  tubes 
should  be  introduced  into  the  kidney  with  care,  as  they  frequently  cause 
pain. 

The  Remarlcs. — The  kidney  itself  may  form  part  of  the  walls  of  a  large 
abscess  in  the  lumbar  region.  If  the  kidney  be  much  enlarged,  the  lumbar 
incision  should  be  placed  farther  forward  at  the  outset  or  carried  in  that 
direction  afterward.  A  movable  kidney  should  be  held  firmly  while  being 
opened  if  pus  is  present ;  if  cysts  only  are  present,  this  manoeuvre  is  of  less 
importance.  In  either  instance  a  movable  kidney  should  be  anchored  to 
the  borders  of  the  wound,  to  secure  proper  retention  there  during  recovery 
and  afterward. 

The  haemorrhage  attending  incisions  of  the  kidney  can  be  controlled  by 
pressure  made  on  the  pedicle  of  the  exposed  organ.  Alternate  superficial 
and  deep  sutures  are  admirably  adapted  to  secure  closure  of  the  incisions. 

Ransohoff  expresses  the  following  conclusions  regarding  operation  for 
renal  calculus :  "  1.  An  absolute  diagnosis  of  stone  can  not  be  made.  2. 
Nephrolithotomies  may  be  divided  into  those  of  necessity  and  those  of  choice. 
In  anuria  and  profuse  hsematuria  delay  is  fatal.  3.  Pyuria  and  microscopical 
haimaturia,  as  indications  of  beginning  destructive  changes,  are  positive  indi- 
cations for  operative  exploration.  4.  The  oblique  incision  is  to  be  preferred 
for  the  ease  with  which  it  permits  the  exploration  of  the  entire  kidney.  5. 
Acupuncture  is  not  to  be  relied  upon.  6.  Incision  should  be  made  along 
the  convex  border  and  only  when  the  circulation  is  controlled  by  digital 
compression.  T.  Incisions  into  the  pelvis  for  exploration  and  for  removal 
of  a  stone  are  to  be  avoided.  8.  Primary  nephrectomy  for  stone  should  be 
reserved  for  extreme  cases.  9.  Primary  union  by  suture,  where  possible, 
makes  nephrolithotomy  an  ideal  operation.  10.  Tight  packing  of  the  kidney 
wound  and  perirenal  space  endangers  the  nerve  sujjply  of  the  colon.     11. 


OPERATIONS   ON  VISOKRA   CONNECTED   Willi    IMMtlTONyKUM.     ,S41 

Nei)lir(»rrlia])liy  shoiild  form  tho  closing  ac;L  of  every  operation  wliicli  lius 
seriously  ilistiirbed  the  relations  of  the  kidneys." 

If  acute  suppression  of  urine  follow  nephrolithotomy,  etc.,  copious  in- 
travenous saline  injections  are  often  of  great  service  (Mcliurney).  Wiien 
tliere  is  reason  to  believe  that  the  supj)ression  is  due  to  stone  in  the  oppo- 
site kidney,  remove  the  stone  at  once  if  feasible.  The  splitting  of  the  cap- 
sule of  the  kidney,  exposure,  acupressure,  and  manipulation  of  the  organ,  in 
cases  of  nephralgia — when  stone  could  not  be  found  after  the  most  careful 
searcli — have  been  followed  often  by  prompj;  and  surprising  relief  from  pain. 
Abbe^  JoJuisofi,  and  others  have  called  attention  to  this  matter  in  such  a 
marked  nuinner  as  to  emi)hasize  its  importance  as  a  justifiable  measure  before 
advising  removal  of  the  kidney  in  intractable  cases  of  doubtful  cause. 

The  Results. — In  nephrotomy  the  general  death  rate  is  about  20  per  cent. 
In  calculus  pyelitis  the  death  rate  is  about  43  per  cent;  hydronephrosis,  40 
per  cent;  for  other  causes  a  much  less  per  cent. 

Nephrectomy. — Nephrectomy  consists  in  the  removal  of  the  whole  or 
a  part  of  the  kidney  for  cure  of  tumor,  fistula^,  and  those  conditions  not 
relieved  by  the  preceding  kidney  operations.  Lumbar  and  abdominal  neph- 
rectomy indicate  the  routes  of  entry  to  the  kidney,  complete  and  partial 
nephrectomy  explain  the  limit  of  the  removal  of  kidney  substance. 

Before  attempting  the  removal  of  a  kidney  for  disease,  the  ascertainment 
of  the  presence  and  condition  of  its  fellow  is  manifestly  important.  It  is 
estimated  that  in  one  in  four  thousand  persons  a  solitary  kidney  is  present. 
The  knowledge  gained  by  physical  examination  and  the  known  relation  of 
certain  diseases  to  the  kidneys,  combined  with  catheterization  of  the  ureters 
and  cystoscopy,  offer  the  means  of  determining  the  comparative  condition 
of  the  organs  before  operation  (page  882).  The  examination  of  the  kidney 
through  an  abdominal  incision  with  the  hand  is  not  an  uncommon  practice. 
The  patient  should  be  thoroughly  prepared  by  therapeutic  means  and  in  an 
aseptic  manner  for  the  operation  of  nephrectomy. 

Lumbar  Nephrectomy. — The  line  of  incision  in  this  operation  is  varied, 
according  to  the  demands  of  the  case  and  the  fancy  of  the  operator.  //*  the 
kidney  be  but  slightly  enlarged  and  not  adherent,  a  single  oblique  incision, 
beginning  at  the  outer  border  of  the  erector  spinse  an  inch  below  the  last  rib 
and  going  forward  and  downward  to  the  iliac  crest,  and  even  curving  forward 
above  the  crest,  if  greater  room  be  needed,  affords  an  admirable  method  of 
approach  (Figs.  1042  and  1044),  If  the  kidney  be  of  large  size  and  much 
adherent,  considerable  room  will  be  needed  for  its  removal.  In  this  case  the 
oblique  primary  incision  is  made  first,  and  supplemented  thereafter  by  either 
a  superior,  middle,  or  inferior  transverse  incision,  according  to  the  demands 
of  the  operation  as  based  on  the  examination  of  the  kidney  made  through 
the  primary  incision.  In  neither  instance,  however,  is  the  peritonaeum  pur- 
posely involved  in  the  incision. 

The  Operation. — Cleanse  the  field  of  operation  thoroughly  and  place  the 
patient  so  as  to  expose  the  wound  to  a  good  light ;  make  the  oblique  incision 
already  mentioned,  dividing  the  tissues  successively  down  to  the  kidney,  if 
practicable  ;  examine  to  ascertain  the  condition  of  the  parts  with  the  hand 


842 


OPERATIVE   SURGERY. 


introduced  into  the  incision ;  make,  if  needed,  the  necessary  supplementary 
transverse  incision  at  the  point  best  intended  to  facilitate  the  examination  and 
removal  of  the  organ  ;  draw  the  borders  of  the  wound  well  asunder  and  arrest 
hemorrhage ;  with  care  enucleate  the  kidney  from  the  fatty  capsule,  if  advisa- 
ble, by  means  of  the  finger  or  a  blunt  dissector ;  if  not,  separate  the  fatty  cap- 
sule, together  with  the  kidney,  from  the  surrounding  tissues ;  push  the  kidney 
into  the  wound  as  far  as  practicable  by  abdominal  pressure,  and  define  the  ped- 
icle; with  care  isolate  the  pedicle  as  much  as  j^ossible ;  raise  the  kidney  from 


Fig.  1045. — The   operation   of   neplu'ectomy,   kidney  lying   outside,      a . 
a.  Subsidiary  renal  artery,     h.  Renal  vein.     c.  Ureter. 


Renal  artery. 


its  bed  and  bring  it  outside  the  wound  (Fig.  1045),  if  feasible,  and  cause  it  to 
be  held  steadily,  without  traction,  by  an  assistant ;  note  the  pulsation  of  the 
renal  artery,  and  with  it  as  a  guide  isolate  the  ureter  and  vessels  from  each 
other;  tie  firmly  en  masse  the  vessels  with  a  strong  silk  ligature  carried  into 
position  by  means  of  a  large  aneurism  needle  or  ligature  carrier  (Fig.  1035) : 
isolate  and  catch  the  ureter  with  forceps ;  sever  the  pedicle  at  a  safe  distance 
from  the  ligature  with  scissors;  cut  off  the  ureter  and  remove  the  kidney  mass. 

The  Treatment  of  the  Ureter. — If  the  ureter  be  much  diseased  it  should 
be  thoroughly  cleansed,  the  end  surrounded  with  gauze  and  brought  for- 
ward and  fixed  in  the  abdominal  wound  with  a  safety  pin  (Thornton),  or 
carried  through  an  opening  in  the  loin  (Morris),  or  it  may  be  isolated  as  low 
down  as  possible,  ligatured,  the  extremity  cauterized  and  returned  to  the 
abdominal  cavity.  If  healthy,  simple  ligature  and  cauterization  of  the  end 
will  suffice.  In  the  instance  of  tuberculous  kidney  the  ureter  may  be  in- 
volved, and  therefore  should  be  removed  (page  8G8)  and  not  returned  to  the 
abdominal  cavity  unless  uninfected. 

The  Treatment  of  the  Pedicle. — The  vessels  may  be  tied  in  two  or  three 
bundles,  or,  as  remarked,  en  masse.     The  latter  plan  is  often  employed,  and 


Ol'KliATIoNS   OX   VISCKI{A   ("ONNKCI'KI)   Wl'l'll    I'HKlToX .KUM.     .s;43 

tlie  results  are  better  tluin  wlien  the  vessels  are  isolated  and  tied  independ- 
ently, as  secondary  ha'niorrhage  appears  to  be  more  comtnoidy  associated 
with  tlie  latter  })lan.  A  liijature  applied  at  either  side  of  the  line  of  the 
proposed  division  of  the  pedicle  is  serviceable.  The  application  of  a  strong 
clamp  to  the  outer  limit  of  the  pedicle  is  highly  commendable,  especially 
when  a  danger  of  the  escape  of  infecting  ])roducts  from  the  kidney  pelvis 
may  follow  the  division  of  the  pedicle.  In  fact,  the  clamp  is  often  em- 
ployed in  lieu  of  the  ligature,  and  in  the  great  majority  of  instances  it 
meets  satisfactorily  the  demands,  tiiough  an  occasional  secondary  ha;mor- 
rhage  serves  to  admonish  the  surgeon  of  an  nnccrtainty  attending  its  use. 
It  is  sometimes  quite  impossible,  at  first,  to  form  a  pedicle  at  a  safe  distance 
from  the  vena  cava,  then  a  long,  strong  ligature  is  carried  around  the  base 
of  the  growth  by  means  of  an  aneurism  needle  and  drawn  tightly  by  the 
fingers  or  an  ecraseur  and  the  kidney  cut  away  as  close  to  the  ligature  as  is 
safe.  In  some  instances  it  may  be  necessary  to  leave  behind  a  small  portion 
of  the  kidney  to  insure  securer  hold  of  the  ligature.  Incautious  separation 
of  a  large  growth  from  tlie  vena  cava  may  cause  profuse  and  often  fatal 
haemorrhage  from  cutting  or  tearing  of  that  vessel.  If  the  vena  cava  be 
torn,  compress  the  bleeding  point  in.<tantly  with  the  fingers  of  one  hand 
and  the  aorta  with  those  of  the  other ;  cause  an  assistant  to  compress  tlie 
vena  cava  at  the  upper  and  lower  limits  of  the  field  of  operation,  then 
remove  the  direct  pressure  from  the  wound  of  the  vena  cava,  sponge  away 
the  blood  and  find  the  injured  point ;  unite  the  divided  borders  of  the 
venous  wound  with  a  continuous  catgut  suture  (Weir).  After  the  removal 
of  the  diseased  structures  by  piecemeal  cutting,  the  pedicle  is  secured  and 
tied  in  as  deliberate  and  efficient  a  manner  as  possible  at  a  proper  distance 
from  the  large  vessels.  Xo  tension  should  be  made  on  the  pedicle  during 
its  ligature  or  division,  as  the  proper  relations  of  its  structures  would  then 
be  disturbed,  and,  after  division  is  made,  their  consequent  unequal  retraction 
would  render  the  ligature  insecure. 

Abdominal  Nephrectomy. — The  abdominal  route  is  selected  in  the  in- 
stances of  large  tumors,  fat  subjects,  lateral  deformity  of  the  spine,  those 
cases  in  which  much  room  for  examination  and  manipulation  is  required, 
and  those  that  offer  a  minimum  danger  of  peritoneal  infection,  as  well  as 
where  examination  of  the  other  kidney  is  demanded.  The  initial  incision 
may  be  made  through  the  linea  alba  or  the  linea  semilunaris  (Langenbiich). 
The  latter  is  usually  selected,  as  it  leads  more  directly  to  the  kidney  and 
ureter,  and  offers  less  exposure  of  the  peritoneal  surface  to  the  exigencies  of 
the  operation.  The  late  Greifj  Smith  regarded  an  incision  made  through 
the  outer  fibers  of  the  rectus  muscle  with  especial  favor,  as  then  the  fascial 
tissues  remain  intact. 

The  Operation. — ]\Iake  an  incision  into  the  abdominal  cavity  not  less  than 
four  inches  in  length  in  tiie  line  already  indicated  (Fig.  9G3),  with  its  center 
opposite  the  navel ;  interpose  a  large,  fiat  sponge  or  abundant  aseptic  gauze 
to  hold  aside  the  intestines  and  absorb  the  oozing  blood ;  introduce  the  hand 
into  the  abdomen  and  examine  carefully  the  condition  of  the  kidney  ;  shut 
off  the  peritoneal  cavity  from  the  field  of  operation  with  sponges  or  pads; 


844  OPERATIVE  SURGERY. 

expose  the  kiducy  by  tearing  through  the  peritoiueum  where  it  forms  tlie 
outer  layer  of  the  mesocolon  (Fig.  1034,  e),  thus  avoiding  the  nutrient  ves- 
sels of  the  colon ;  separate  the  front  of  the  kidney  from  the  perirenal  fat 
with  the  fingers ;  expose  the  renal  vessels  through  the  opening  by  drawing 
inward  strongly  the  inner  border  of  the  wound  with  a  wide  hooked  retractor, 
aided  by  outward  displacement  of  the  kidney ;  isolate  the  vessels  with  the 
fingers  aided  by  a  blunt  dissector,  and  carry  around  them  with  a  large 
aneurism  needle  a  strong  silk  ligature ;  tie  tlie  ligature  firmly,  and  catch 
the  ureter  with  forceps;  isolate  the  kidney  completely  with  the  fingers  and 
sever  the  vessels  and  the  ureter  at  safe  distances  from  their  points  of  con- 
striction ;  raise  the  kidney  mass  from  the  wound,  and  insert  sponges  or 
gauze  to  arrest  oozing;  cleanse  the  wound  of  all  escaped  fluids,  and  arrest 
the  bleeding  points.  If  drainage  be  required,  the  end  of  the  tube  is  caused 
to  escape  through  an  opening  made  at  the  loin.  The  peritoneal  opening 
in  the  mesocolon  need  not  be  closed  unless  the  external  wound  be  infected, 
as  the  parts  are  promptly  pressed  into  position  by  the  intestines.  The 
abdominal  wound  is  closed  and  dressed  as  in  other  instances. 

The  operation  by  incision  through  the  linea  alba  differs  in  no  essential 
regard  from  that  just  described. 

The  Precautions. — Too  vigorous  or  ill-directed  manipulation  may  wound 
the  colon  as  it  lies  upon  the  diseased  kidney,  therefore  the  gut  should  be 
scrutinized  for  the  presence  of  such  a  mishap.  The  peritonaeum  covering 
the  tumor  may  be  torn  in  the  efforts  to  isolate  and  remove  the  growth,  there- 
by opening  the  way  to  infection  of  the  peritoneal  cavity.  The  separation  of 
an  extensive  growth  from  the  vena  cava  has  but  rarely  caused  fatal  or  even 
profuse  ha3morrhage  The  nutrient  vessels  of  the  colon  associated  with  the 
inner  layer  of  the  mesocolon  should  not  be  injured,  as  gangrene  of  the  gut 
is  liable  to  result.  If  the  wound  has  been  infected  by  pus,  etc.,  during  the 
removal  of  the  organ,  gauze  packing  and  lumbar  drainage  should  be  utilized. 
A  large  vein  lying  in  the  outer  layer  of  the  mesocolon  may  be  severed  in 
going  across  to  the  kidney  unless  care  be  taken.  Sometimes  a  large  vein 
lies  behind  the  kidney  and  ureter,  that  bleeds  freely  during  separation  of 
the  tumor.  A  too  small  abdominal  incision  is  objectionable,  for  it  does  not 
meet  the  demands  of  cautious  exploration  and  manipulation. 

The  Remarks. — Plenty  of  room,  close  observation,  and  careful  treatment 
of  the  peritonaeum  and  pedicle  are  cardinal  tenets  of  successful  nephrectomy. 
Enucleation  of  the  kidney  from  the  fatty  capsule  is  often  easier  to  accom- 
2:)lish  than  separation  of  the  fatty  capsule  from  the  contiguous  tissues.  Scis- 
soi'S  curved  on  the  flat  are  an  admirable  aid  in  enucleation  of  the  tumor.  The 
measures  for  avoiding,  and  for  the  treatment  of,  shock  should  be  at  hand. 
The  ileo-costal  space  should  be  made  as  commodious  as  possible  by  proper 
flexion  and  well-supported  inclination  of  the  body.  K'u)iig,  to  secure  freer 
access  to  the  kidney  than  the  ordinary  incision  affords,  adds  to  the  lower  end 
of  the  ileo-costal,  vertical,  or  oblique  incision,  an  oblique  extension  toward 
the  navel  going  often  to  the  outer  border  of  the  rectus  abdominis  (Figs. 
1043  and  1043).  The  tissues  are  divided  down  to  the  peritonaeum,  the  hand 
is  inserted  into  the  perpendicular  cut,  and  the  peritonseum  pressed  forward. 


OPERATIONS  ON    VISCKRA   CONNKCTKD    Willi    I'KRITON^OUM.     845 

tStill  I'lirlher  room  ciiii  he  gained  by  tninsversc  ilivisioii  of  tlie  peritonuiiim, 
wliich,  however,  must  be  carefully  guarded  against  infection,  and  closed  as 
j)romj)tly  as  possible.  Increased  room  for  inaTiipulation  and  opportunity  for 
observation  are  secured  by  drawing  u])\\ard  the  costal  cartilages  antl  by  re- 
section of  the  twelfth  rib.  In  the  event  of  the  inability  to  properly  control 
seconilary  luvmorrlKige  by  orilinary  measures,  a  firm  tamj)onade  of  antise{)tic 
gauze  should  be  a})plietl  and  confined  in  place  for  four  or  live  days,  and  the 
removal  should  be  conducted  with  extreme  care  to  avoid  a  recurrent  bleed- 
ing. Mikulicz's  tampon  (Fig.  \o\'l)  answers  the  purpose  admirably;  pack- 
ing for  forty-eight  hours  is  quite  sufficient  to  arrest  troublesome  oozing- 
When  the  colon  is  much  raised  by  a  marked  growth  the  posterior  layer  of 
the  mesocolon  usually  presents  itself  in  the  incision  through  the  linea  semi- 
lunaris. The  cut  edges  of  the  peritonajum  located  above  the  seat  of  the 
kidney  should  be  closely  and  finally  apposed  by  sewing,  especially  when  in- 
fection beneath  is  present  or  anticipated. 

The  After-treatment. — After  removal  of  the  kidney,  carefully  inspect  the 
pedicle  and  note  that  all  haemorrhage  is  securely  arrested  ;  examine  the  peri- 
tonaeum for  rents,  and  close  any  that  may  be  found  with  a  continuous  suture 
of  catgut;  rejiair  the  colon,  if  injured  ;  cleanse  the  wound;  arrest  bleeding; 
introduce  a  large  drainage  tube  to  the  bottom  of  the  wound,  along  with 
strips  of  iodoform  gauze  if  infection  or  oozing  be  anticipated  ;  close  the 
wound  with  deep  sutures  of  chromocized  catgut  and  superficial  ones  of  silk- 
^vorm  gut ;  dress  as  usual,  confining  the  dressing  in  place  with  a  binder. 
Prompt  union  is  quite  common  in  these  cases.  If  suppuration  ensues,  the 
usual  flushing  through  the  tube  is  practiced. 

The  Choice  of  Operation. — Briefly  stated,  the  lumbar  incision,  supple- 
mented with  one  or  more  of  the  secondary  incisions,  is  suitable  for  all  cases, 
except  perhaps  those  in  which  adiposity  or  deformity  of  the  patient  seriously 
interferes  with  the  approach,  examination,  and  treatment  of  the  pedicle,  and 
especially  with  the  arrest  of  ha3morrhage  attendant  thereon.  In  all  cases  the 
abdominal  incision  gives  one  good  command  of  the  treatment  of  the  pedicle 
and  ureter,  and  of  the  complicated  relations  of  the  tumor  to  the  important 
structures  at  the  median  line  of  the  body,  and  the  opportunity  to  examine 
the  other  kidney.  It  is  rare,  indeed,  however,  that  these  benefits  are  com- 
mensurate with  the  evils  resulting  from  exposure  and  manipulation  of  the 
peritouEeum  and  its  contents,  to  say  nothing  of  the  possible  impairment  of 
the  circulation  of  the  colon,  the  demands  of  secondary  htvmorrhage,  and 
suitable  drainage.  Expert  operators  can  employ  the  anterior  incisions  with 
far  greater  safety  than  can  those  of  ordinary  attainment. 

Tlie  Results. — As  might  be  supposed,  the  death  rate  in  abdominal 
nephrectomy  exceeds  that  of  the  lumbar  method,  due  in  part  to  the  pres- 
ence of  more  extensive  disease  and  greater  danger  of  peritoneal  infection  in 
the  latter  cases.  The  general  death  rate  of  the  abdominal  method  is  from 
40  to  50  per  cent,  of  the  lumbar  from  20  to  30.  The  general  death  rate  of 
nephrectomy  for  suppurative  calculous  disease  is  from  30  to  40  per  cent. 
In  special  instances  of  personal  practice  rates  as  low  as  7  to  15  per  cent  are 
reported  ;  for  hydronephrosis,  5.75  per  cent. 


346  OPERATIVE  SURGERY. 

Partial  Nephrectomy. — The  removal  of  only  the  affected  part  of  a  kid- 
ney, for  cure  of  injuries  and  morbid  growths,  has  been  practiced  successfully 
on  many  occasions.  Instances  are  noted  of  partial  ne])hrectomy  for  the 
removal  of  circumscribed  malignant  disease,  witli  uneventful  recovery  and 
apparently  final  cure.  Hardly  enough  knowledge  is  yet  at  hand  regarding 
this  practice  to  emphasize  the  wisdom  of  the  procedure,  except  perhaps  in 
those  cases  in  which  there  is  reason  to  believe  that  the  remaining  kidney  is 
in  need  of  physiological  assistance.  It  is  proper  to  note  in  this  connection 
that  Bradford's  experiments  on  dogs  demonstrate  that  excision  of  a  portion 
of  the  kidney  is  followed  by  an  aqueous  increase  in  the  urine  and  in  direct 
proportion  to  the  amount  of  the  organ  removed,  also  that  the  function  of 
the  portion  of  kidney  remaining  appears  to  be  able  to  excrete  a  compara- 
tively increased  amount  of  urea. 

Extraperitoneal  Nephrectomy  (abdominal  incision).— Extraperitoneal  re- 
moval of  the  kidney  can  be  practiced  in  simple  cases  before  or  after  entrance 
to  the  peritoneal  cavity.  In  the  first  instance  the  abdominal  incision  is  car- 
ried down  only  to  the  peritonaeum,  and  thereafter  the  peritonseum  is  reflected 
from  the  abdominal  wall  around  to  the  kidney,  which  is  then  removed  in  the 
usual  manner.  In  the  second  instance  the  incision  is  made  into  the  peri- 
toneal cavity,  the  kidney  is  examined,  and,  if  the  conditions  warrant  its 
removal,  the  outer  border  of  the  incision  through  the  mesocolon  is  sewed  to 
the  inner  border  of  the  incision  through  the  parietal  peritoneum,  thus  con- 
stituting substantially  a  subperitoneal  route  through  which  the  kidney  is 
released  and  removed.  It  is  important,  however,  in  this  connection  to  note 
that  valuable  time  and  opportunities  may  be  sacrificed  not  infrequently  in 
the  practice  of  ingenious  though  unwise  technique. 

Puncture  of  the  Kidney. — Puncture  (from  without)  of  the  kidney  for  diag- 
nostic purposes  may  or  may  not  be  a  dangerous  procedure,  depending  on  the 
care  with  which  it  is  practiced  and  the  environment  of  the  organ  as  influenced 
by  the  morbid  processes  connected  with  it.  According  to  Morris  :  "  The  point 
selected  for  puncturing  will  depend  on  circumstances.  If  there  be  a  spot 
over  the  swelling  which  is  thin,  soft,  prominent,  or  fluctuating,  the  trocar 
can  be  inserted  there.  A  point  which  is  not  seldom  indicated  is  midway 
between  the  umbilicus  and  the  anterior  superior  spine  of  the  ilium,  or  half 
an  inch  below  and  an  inch  and  a  half  to  the  side  of  the  navel.  When  no 
particular  spot  is  suggested  by  the  discoloration  or  prominence,  no  better 
place  can  be  selected  on  the  left  side  than  an  inch  in  front  of  the  last  inter- 
costal space ;  but  if  the  tumor  be  of  the  right  side  this  is  too  high,  as  the 
liver  will  probably  be  traversed.  If  there  is  no  indication  for  operating  else- 
where, the  best  spot  to  select  when  the  kidney  is  of  the  right  side  is  half- 
way between  the  last  rib  and  the  crest  of  the  ilium,  between  two  and  two 
and  a  half  inches  behind  the  anterior  superior  spine  of  the  ilium. 

"  In  performing  the  operation  the  operating  trocar  should  be  inserted 
without  any  previous  incision  of  the  skin.  If  a  larger  trocar  be  used,  an 
incision  through  the  integument  and  muscles  is  sometimes  made  before 
introducing  the  instrument.  The  dangers  of  the  operation  are  very  slight. 
If,  however,  the  puncture  be  made  too  far  forward  and  through  non-adherent 


Ol'KHA'riONS   ()\    \1S('1<:KA   (;()NNK(THI)   with    I'lllMTOXyEUM.     847 

])crit()iia'iim,  some  of  tlio  contents  of  tlio  cyst  uii^flit  ho  oxtruvasiitcd  into  the 
])i'rit()n(';il  cavity  oji  withdrawing  the  trocar,  an  accident  which  has  proved 
faial  ill  iiiiui'  than  one  case.  Tiiere  is  also  the  danger  of  wounding  the  intes- 
tine, whicli,  as  a  rule,  is  in  front  of  the  end  adherent  to  the  tumor;  and  if  the 
trocar  is  lung  and  is  thrust  too  far  inward  it  might  penetrate  some  im[)ortant 
blood-vessel  causing  dangerous  if  not  fatal  h;emorrhage.  The  penetration  of 
the  thin  edge  of  the  liver  with  an  as])iratiiig  needle,  thougli  to  be  avoided,  is 
not  an  accident  likely  to  be  followed  by  any  ill  consequence.  The  instrument 
siiould  not  be  introduced  too  ne;ir  the  ribs  for  fear  of  wounding  tlie  pleura." 
l*uncture  and  drainage  f(n'  hydi"onc})lirosis  should  be;  abandoned. 

Wounds  of  the  Kidney. — 'I'he  kidney  suifers  from  external  violence  not 
infre(juently  in  various  degrees  of  severity.  Wounds  of  the  cortical  sub- 
stance oidy  are  less  dangerous  than  are  those  involving  the  medullary,  for 
in  the  latter  instance  the  pelvis  of  the  kidney  is  apt  to  be  involved  when 
luvmorrhage  is  much  more  severe  and  urinary  extravasation  more  common. 
However,  if  the  vessels  are  not  injured,  and  the  urine  is  healthy,  the  outlook 
is  favorable  even  when  considerable  extravasation  of  blood  and  nrine  has 
taken  place.  If  the  cortex  alone  is  injured,  bloody  urine  will  not  appear, 
and  the  urine  will  not  go  astray.  In  wounds  limited  to  the  pelvis  of  the 
kidney  hoamorrhage  is  comjiaratively  small  and  urinary  extravasation  quite 
the  reverse.  In  these  cases  blood  in  the  urine  is  in  small  quantity  and  seen 
often  only  at  the  outset,  while  the  amount  of  urine  passed  is  lessened  because 
of  its  escape  through  the  oj)cning. 

The  Operative  Treatment. — The  chief  indications  of  operative  treatment 
in  wounds  of  the  kidney  are  usually  directed  to  the  injured  organ,  and  con- 
sist in  the  prompt  arrest  of  htemorrhage,  the  early  detection  and  relief  of 
urinary  extravasation,  and  the  prevention  of  infection.  When  penetrating 
violence  causes  the  wound,  with  involvement  of  the  peritoneal  cavity,  the 
concomitant  injuries  should  be  sought  for  and  dealt  with  as  already  indicated 
(page  GG7  et  seq.),  and  the  kidney  itself  treated  as  circumstances  seem  to 
require.  But  in  wounds  due  to  other  varieties  of  violence,  or  to  penetrating 
when  unaccompanied  with  peritoneal  invasion,  the  lumbar  incision — pre- 
ceded probably  by  aspiration — should  be  made  the  same  as  in  exposure  of  the 
kidney  for  other  reasons.  The  fact  that  the  majority  of  injuries  of  the 
kidney  recover  without  operation  should  not  lead  the  surgeon  to  indulge  in 
complacent  procrastination  until  too  late  to  wisely  meet  the  demands  of  the 
preceding  indications.  And  in  this  connection  it  should  be  recalled  that 
primary  operative  practice  is  productive  of  better  final  results  than  is  the 
secondary.  Therefore,  when  the  early  symptoms  point  to  the  presence  of 
severe  or  continuous  bleeding  of  decided  character,  or  to  urinary  extravasa- 
tion, prompt  surgical  exposure  of  the  seat  of  the  injury  should  be  made  by 
enlargement  of  the  primary  wound  or  through  a  fresh  incision  at  the  loin. 
After  exposure  of  the  organ  and  evacuation  of  the  extravasated  fluids  the 
extent  of  the  injury  can  be  ascertained.  Bleeding  points  should  be  sought 
for  and  tied,  and  vigorous  oozing  controlled  by  temporary  packing  with 
gauze  pending  a  freer  exposure  of  the  field  of  injury  and  its  thorough 
cleansinjr  with  fluid.     Large  clots  of  blood  should  be  removed  and  the  sur- 


848 


OPERATIVE   SURGERY. 


Fig.  1046.— Suture  of  the 
kidney,  longitudinal 
wound,  a,  c.  End  su- 
tures, h.  Intermediate 
suture. 


faces  wiped  as  dry  as  possible  with  gauze.  Tiie  oozing  surface  is  then 
exposed  and  the  cluiracter  of  the  injury  determined.  If  a  clean  cut  not 
involving  the  pelvis  be  noted,  the  cut  should  be 
closed  at  once  by  sewing  with  interrupted  sutures 
(Fig.  104G).  Suturing  (ohromicized  catgut)  should 
commence  at  either  end,  approaching  the  middle  of 
the  wound,  as  the  union  is  completed,  with  coarse 
sutures  to  prevent  tearing.  If  the  pelvis  is  invaded 
and  previous  infecting  disease  is  present,  the  pelvic 
cavity  should  be  thoroughly  cleansed,  the  wound 
closed  as  before,  or  by  through  and  through  sewing 
(Fig.  1047)  with  coarse  sutures,  or  partly  closed 
around  a  drainage  tube  already  surrounded  with 
gauze,  as  circumstances  require.  If  a  gunshot, 
contused,  or  lacerated  wound  not  involving  the 
pelvis  be  present,  firm  packing  with  gauze  will 
control  the  oozing  and  leave  also  suitable  space 
for  drainage.  If  the  wound  involves  the  pelvis  of 
the  kidney,  thorough  cleansing,  followed  by  pack- 
ing to  arrest  oozing,  may  be  all  that  is  needful. 
Extensive  disorganization  of  the  kidney  or  destruc- 
tion of  the  vessels  calls  for  total  nephrectomy  at 
once.  Limited  disorganization  may  be  amenable  to  partial  nephrectomy 
with  union  by  sewing,  or  packing  and  drain- 
age only  may  suffice.  If  the  capsule  is  in- 
tact and  the  kidney  overdistended  with 
fluid,  incision  into  and  thorough  cleansing 
of  the  cavity  are  indicated.  Infected  wounds 
and  those  in  which  doubt  of  prompt  and 
final  repair  is  entertained  should  be  drained. 
Healthy  aseptic  wounds  should  be  closed. 
The  present  limited  knowledge  of  the  scope 
of  operative  attacks  on  the  kidney  and  of 
the  devious  characteristics  of  its  injuries, 
together  with  the  limited  space  for  expres- 
sion, make  it  impossible  to  do  more  at 
this  time  than  to  present  a  general  outline 
of  treatment. 

The  Complications.  —  Wounds  of  the 
large  vessels  of  the  kidney  are  so  urgent 
that  they  may  easily  prove  fatal  at  the  out- 
set, and  if  not,  prompt  and  decisive  action 
only  will  save  the  patient.  Extensive  extrav- 
asations of  blood  ben-eath  the  peritonaeum, 
extending  sometimes  to  the  mesentery,  meso- 
colon, pelvic  cavity,  etc.,  are  of  great  significance  because  of  the  inability  to 
remove  the  blood,  and  principally  because  of  the  dangers  attending  its  becom- 


FiG.  1047.  — Suture  of  the  kidney, 
through  and  through  suture. 


OrKKATIONS  ON    VISCERA   CONNIOCTKI)    WITH    I'KUlTON^UiM.     849 

ing  infected.  The  pain  and  vesical  tenesmus  attending  the  free  entrance  of 
blood  into  the  bladder,  suijpleiiiented  with  the  lial)ility  of  infection,  demand 
its  prompt  removal  either  by  means  of  a  large  evacuating  catheter  or  tlie 
additional  use  of  a  bladder  evacuator  (Fig.  ).  Failing  in  these,  the 
squeezing  of  the  organ  by  the  hands  passed  through  a  small  cceliotomy  inci- 
sion may  bo  practiced  (Willard),  and  even  a  free  incision  into  the  organ  itself 
for  the  purpose  nuiy  be  necessary.  Anuria  from  injury  of  one  or  both  kid- 
neys, from  shock,  from  previous  disease  of  the  organ,  and  from  injury  of  a 
single  kidney,  also  ur;\3mia  which  may  depend  on  pressure  from  without 
due  to  pseudo-hydroneplirosis,  should  be  anticipated,  and  ample  provision 
made  for  prevention  and  cure.  The  presence  of  peritoneal  rupture  and 
peritoneal  extravasation  of  blood  or  urine  should  be  determined  and  the  dan- 
gers promptly  obviated  by  washing  and  repair.  Tiiis  variety  of  injury  is 
more  liable  to  happen  before  ten  years  of  age,  as  absence  of  the  fatty  capsule 
during  this  period  brings  the  peritonwura  into  closer  contact  with  the  kidney 
and  therefore  renders  it  less  resistant  to  injury.  Severe  renal  colic  depend- 
ent on  the  presence  in  the  ureter  of  passing  blood  clots  is  not  infrequent  in 
these  cases.  A  torn  or  plugged  ureter  lessens  the  amount,  and  modifies  the 
character,  of  the  contents  of  the  bladder,  blood  not  appearing.  In  the  former 
instance  subperitoneal  extravasation  of  blood  and  urine  may  require  free 
incision  and  drainage.  Prolapse  of  the  kidney  through  the  wound  is  a  rare 
complication,  and  is  quite  readily  met  by  restoration  of  the  organ  to  and 
fixation  in  the  normal  position.  The  possibility  of  the  occurrence  of  sec- 
ondary hfemorrhage  should  not  be  ignored,  and  care  in  securing  the  vessels 
is  the  most  serviceable  preventive. 

The  Remarks. — Usually  the  injuries  are  unilateral  and  both  kidneys  are 
healthy,  therefore  the  wounds  are  non-infected  except  from  without.  Haem- 
orrhage from  the  cortical  substance  is  less  severe  than  from  the  medullary, 
because  of  the  difference  in  the  arrangement  of  the  vessels  in  the  respective 
structures. 

Tlie  After-treatment. — Careful  cleansing,  good  drainage,  and  proper 
attention  to  the  complications  and  sequels  embody  the  indications  and  sug- 
gest the  manner  of  treatment. 

The  Resiilts. — There  are  not  a  few  conditions,  such  as  a  single  kidney, 
diseased  kidneys,  injury  of  both  kidneys,  etc.,  which  almost  forbid  the  enter- 
tainment of  the  idea  of  a  successful  issue  from  any  plan  of  action.  The 
death  rate  from  gunshot  wounds  is  about  80  per  cent;  from  punctured, 
about  25  per  cent;  and  in  rupture,  about  33  per  cent  without  and  23  with 
operative  treatment.  Primary  nephrectomy  gives  a  death  rate  of  about  25 
per  cent,  and  secondary  of  about  39  per  cent.  The  performance  of  nephrec- 
tomy increases  the  rate  of  recovery  about  8  per  cent.  By  the  abdominal 
route  the  rate  of  mortality  is  33.3  per  cent,  by  the  lumbar  about  5  per  cent 
less  (Keen). 

Tiifjier  reports  the  death  rate  of  uncomplicated  cases  of  rupture  at  43, 
and  of  complicated  at  87  per  cent.  Grawitz  reports  the  mortality  rate  at 
46.3  per  cent  in  this  class  of  cases. 


850  OPERATIVE  SURGERY. 

OPERATIONS    ON   THE    UKETEUS. 

The  advisability  of  certain  operatious  on  the  ureters  is  accepted,  the 
labors  of  Van  Hook,  Fenger,  Kelly,  and  others  having  established  their 
utility  beyond  gainsaying. 

The  Anatomical  Poiiiti<. — The  ureter  is  a  fibro-muscular  tube  about  one 
sixth  of  an  inch  in  diameter,  flattened  antero-posteriorly,  having  a  wall  of 
about  one  twenty-fifth  of  an  inch  in  thickness,  nearly  half  of  which  is  com- 
posed of  muscular  tissue.  It  is  notably  elastic,  hence  amenable  to  stretching 
in  either  axis.  It  is  richly  supplied  with  blood  and  therefore  highly  vitalized. 
It  vigorously  resists  manipulative  influences  and  promptly  heals  under  favor- 
able conditions.  The  ureter  varies  in  length  from  ten  to  thirteen  inches. 
The  ureter  maybe  partially  or  wholly  double,  and  be  connected  with  the 
kidney  above  and  the  bladder  below  in  various  abnormal  ways.  In  sixty  per 
cent  of  subjects  it  is  narrowed  at  the  three  following  situations  :  1,  at  a  point 
between  an  inch  and  a  half  and  two  inches  and  a  half  from  the  kidney  ;  3, 
at  each  extremity ;  3,  at  the  place  where  it  crosses  the  iliac  artery  (Halle  and 
Tanquary).  The  abdominal  portion  of  the  ureter  lies  on  the  psoas  muscle 
and  is  covered  by  peritonaeum,  to  which  it  is  so  closely  adherent  as  to  be 
reflected  along  with  that  membrane.  The  genito-crural  nerve  is  closely 
associated  with  it,  and  therefore  not  infrequently  irritated  by  the  presence 
of  calculi  in  the  tube.  The  important  vascular  relations  of  the  ureter  are 
shown  by  Fig.  173. 

The  course  of  the  ureter  from  the  kidney  to  the  brim  of  the  pelvis  cor- 
responds to  a  line  drawn  from  the  junction  of  the  inner  with  the  middle 
thirds  of  Poupart's  ligament  vertically  upward.  The  exact  location  at  the 
brim  is  indicated  by  the  intersection  of  a  horizontal  line  drawn  between  the 
anterior  superior  spines  of  the  ilium  and  a  vertical  one  passing  through  the 
spine  of  the  pubis  (Tourneur).  At  the  brim  of  the  pelvis  the  ureters  are 
about  two  inches  apart.  In  the  pelvis  the  ureter  clings  to  the  pelvic  wall, 
passing  outward  across  the  obturator  fascia,  then  curves  toward  the  bladder. 
In  the  male  it  lies  close  to  the  free  end  of  the  vesicula  seminalis,  and  is 
crossed  at  the  inner  side  and  above  by  the  vas  deferens.  In  the  female  it 
passes  beneath  the  uterine  artery  in  the  broad  ligament,  runs  parallel  with 
and  half  an  inch  behind  the  cervix  uteri,  passes  obliquely  across  the  upper 
third  of  the  vagina,  entering  the  bladder  near  the  middle  of  the  former  pas- 
sage. In  the  bladder  the  ureter  runs  obliquely  through  the  wall  toward  the 
median  line  and  opens  into  the  organ  three  fourths  of  an  inch  from  its  fellow 
and  from  the  urethral  opening.  The  portion  of  the  ureter  below  the  brim 
can  be  palpated  through  the  rectum  in  the  male  and  through  the  vagina  in 
the  female.  Stones  are  arrested  in  the  ureter  most  often  in  the  upper  part, 
with  about  equal  frequency  at  the  middle  and  lower  parts. 

The  ureters  serve  the  active  purpose  of  transmittiug  the  urine  from  the 
kidney  to  the  bladder,  and  the  discharge  is  accomplished  in  an  intermittent 
manner,  occupying  from  ten  to  twenty  seconds  in  the  passage.  The  escape 
of  the  urine  into  the  bladder  is  characterized  by  sudden  intermittent  expul- 
sions, each  lasting  two  or  three  seconds.     Whether  or  not  the  functions  of 


ol'KIJATIOxNS   ON    V1S('K1{A    CONNKCTKI)    WITH    I'ERlTONiEUM.     851 


35V. 


Fi(i.   1U4S.— Iiistniinonts  pinployed  in  operations  on  the  ureter. 

a.  Scalpels,  b.  Small  knife,  c.  Forcipressnre.  d.  Straig^ht  and  curved  scissors,  e,  *. 
Mouse-tooth  and  thumb  forceps.  /.  h.  Hollow-jawed  Jind  common  needle-holders. 
j,  m.  Tiarge  blunt  and  hooked  retractors,  k.  Gum-elastic  urethral  catheter.  I.  Chro- 
micized  catgut,  n,  o.  Tenaculum  and  blunt  hook.  p.  q.  Long  silver  probe  and 
metal  urethral  catheter,  r.  Delicate  curved  and  straight  needles,  s.  Catgut  and 
silkworm  gut.  A  waxed-tip  catheter,  dilating  urethral  catheters,  and  hard-rubber 
urethral  bougies  are  often  serviceable.  Drainage  agents,  gauze  pads,  etc.,  should  be 
provided. 
60 


852  OPERATIVE  SURGERY. 

the  ureter  are  carried  on  in  accordance  with  the  established  physiological 
manner  and  the  urine  escaping  therefrom  has  the  normal  characteristics, 
are  matters  of  great  importance  in  connection  with  the  significance  of  morbid 
changes  in  both  kidney  and  ureter. 

The  exanmiation  to  determine  the  condition  of  the  ureters  is  of  a  com- 
prehensive and  technical  nature.  Their  vesical  openings  and  the  submucous 
ridges  indicating  their  course  through  the  bladder  wall  and  the  urinary 
peculiarities,  can  be  quite  readily  observed  by  means  of  the  cystoscope  (page 
1159).  The  portions  of  the  tubes  contiguous  to  the  vagina  may  be  exposed 
and  examined  as  they  lie  in  the  connective  tissue  through  an  incision 
made  at  the  antero-lateral  wall  of  the  passage,  aided  by  the  introduction 
into  their  lower  extremities  of  a  bougie.  Through  an  oblique  incision 
(Fig.  1044)  and  reflection  Inward  of  the  peritonaeum  and  contiguous  organs, 
the  abdominal  part  of  the  ureter  can  be  brought  into  view  as  it  lies  beneath 
the  peritoneum  closely  associated  with  its  own  and  contiguous  vessels.  If 
the  bladder  and  rectum  be  empty,  the  lower  extremities  of  the  tube  can  be 
palpated  by  introduction  of  the  finger  high  up  into  either  of  these  passages, 
and  although  varying  somewhat  in  position,  they  are  quite  readily  distin- 
guished under  normal  conditions  as  freely  movable  fibrous  cords,  by  direct 
and  bimanual  pressure.  Direct,  deep  abdominal  palpation  made  along  the 
semilunar  line  will  often  disclose  the  presence  of  a  diseased  ureter,  especially 
at  the  brim  of  the  pelvis,  where  the  abdominal  wall  is  thin  and  much  relaxed. 
The  introduction  of  a  suitable  sized,  highly  polished  silk  catheter  into  the 
ureter  (page  851)  enables  one  to  determine  the  presence  of  constriction,  of 
obstruction,  and  approximately  their  nature,  and  perhaps  also  the  condition 
of  the  kidney  itself. 

Wounds  of  the  Ureter, — Wounds  of  the  ureter  commonly  arise  from 
external  force  and  from  operative  violence.  The  former  kind  are  exceed- 
ingly rare  because  of  the  small  size,  firm  structure,  isolated  and  well-protected 
state  of  the  tube.  Those  classed  with  operative  violence  include  the  damage 
incident  to  the  loss  of  substance  from  removal  of  structural  changes  of  and 
those  contiguous  to  the  ureter.  The  ureter,  although  rarely  injured  by 
external  violence,  sometimes  suffers  in  contused,  punctured,  and  gunshot 
wounds  of  the  abdomen.  How  often  stretching  or  crushing  force  causes 
the  rupture  can  not  be  said,  but  at  all  events  the  injury  happens  more  fre- 
quently above  than  below  the  brim  of  the  pelvis,  because  maybe  tlie  tube  is 
crashed  against  the  transverse  process  of  the  first  lumbar  vertebra.  The 
difficulty  of  framing  a  timely  diagnosis  in  these  cases  often  makes  earh^  cure 
impossible.  The  infiltration  and  infection  attending  a  late  diagnosis  renders 
at  the  best  the  detection  and  repair  of  the  rupture  both  diflScult  and  un- 
certain. Puncture,  mcision,  and  drainage  through  the  lumbar  region  or 
the  abdomen  in  front  are  the  primary  measures  employed. 

Puncture  of  the  retroperitoneal  collection  of  fluids  through  the  loin, 
although  sometimes  followed  by  cure,  can  not  be  regarded  as  a  satisfactory 
method  of  practice. 

Lumbar  hicision. — A  free  incision  in  the  ilio-costal  space  seciires  prompt 
escape  of  extravasated  fluids,  provides  good  drainage,  and  affords  opportunity 


()1'KI{ATI()NS   ON    VISCKliA    CONNKC'TRD    WI'I'll    I'KUITONyEUM.     858 

for  the  exploration  essential  to  determine  the  sent  and  extent  of  the  injury, 
espeeially  if  the  opening  be  extended  along  the  iliac  crest.  However,  it  is 
rare  indeed  that  the  opening  in  tlie  ureter  will  be  fouiid  unless  catheterisni 
of  the  tube  from  below  is  practiced.  If  the  opening  is  discovered  it  should 
be  closed  by  sewing,  if  possible;  but,  if  it  can  not  be  found,  or  the  sew- 
ing fails  to  effect  rej)air,  proper  drainage  sliould  be  established  pending 
further  procedures  based  on  the  presence  and  condition  of  the  other  kidney 
and  the  results  of  Nature's  efforts  at  relief.  If  the  ureter  is  entirely  severed, 
union  of  the  divided  ends  by  the  accepted  methods  of  practice  or  suitable 
transplantation  of  the  proximal  end  (page  858)  should  be  carried  into  effect. 
Failing  in  the  wisest  of  these  means,  a  permanent  urinary  fistula  in  the  loin 
is  the  obvious  outcome.  In  the  event  of  failure  of  other  means  these  fistuhu 
can  be  remedied  by  removal  of  the  kidney,  provided  the  other  kidney  be 
present  and  healthy,  and  the  annoyance  from  the  discharge  becomes  intol- 
erable. 

The  Remarks. — In  searching  for  the  ureter  the  fact  that  it  is  carric*! 
forward  with  the  reflected  peritonti'um,  and  that  its  line  of  attachment  to 
this  membrane  is  scarcely  more  than  half  an  inch  external  to  its  connection 
with  the  spinal  column,  should  be  kept  in  view.  The  frequent  prompt 
healing  of  incisions  in  the  ureter  made  by  the  surgeon  should  emphasize  the 
necessity  of  arranging  the  tissues  in  the  instances  of  undetected  injuries  in 
a  manner  best  suited  to  secure  natural  repair.  A  careful  cystoscopic  examina- 
tion to  determine  the  presence  and  condition  of  the  fellow  kidney  should  be 
made  before  radical  means  of  relief  are  attempted. 

Primary  abdominal  incisions  for  the  relief  of  wounds  of  the  ureter  are 
made  according  to  the  nature  of  the  wound.  If  for  contused  wounds,  extra- 
peritoneal approach  is  the  better;  if  for  gunshot  and  punctured  wounds, 
direct  approach  along  the  course  of  the  injury  should  be  practiced.  But  in 
such  wounds  as  these  it  is  hardly  to  be  expected  that  little  else  than  good 
fortune  will  lead  to  suspicion  of  internal  injury  and  its  detection,  particu- 
larly in  the  presence  of  the  exigencies  of  the  occasion.  The  longitudinal, 
the  incom-plete  ohliqiie,  and  transverse  wounds  of  the  ureter  are  closed  by 
Lembert  sutures  as  soon  as  discovered,  and  the  line  of  union  is  fortified  by 
infolding  of  the  peritongeum  or  by  an  omental  graft  (Fig.  888).  If  the  wound 
be  transverse  and  incomplete.  Van  Ilook  advises  the  opening  of  the  trans- 
verse wound  upward  and  downward  longitudinally ;  the  cutting  off  of  the 
four  corners  that  result  from  the  longitudinal  incisions,  and  the  union  of 
the  borders  of  the  modified  wound  transversely,  thus  folding  the  ureter  upon 
itself,  as  in  "  elbowing  "  the  intestine  (Fig.  8G5).  Fenger  suggests  that  this 
operation  will  probably  be  safe  in  extraperitoneal  wounds.  But  if  the  wound 
opens  into  the  peritoneal  cavity,  it  is  not  certain  that  covering  it  with  a  fold 
of  peritona3um  will  be  sufficiently  secure.  He  thinks  it  might  be  safer  to 
complete  the  division  of  the  ureter  and  unite  the  divided  ends  after  the 
manner  devised  by  Van  Hook  {uretero-ureterotomy).  The  complete  trans- 
verse wounds  are  remedied  by  uretero-ureteral  anastomosis  (page  854). 

Primary  nephrectomy  for  relief  from  wounds  of  the  ureter  should  not  be 
entertained.       Other  things  permitting,  secondary  nephrectomy  should  be 


854 


OPERATIVE  SURGERY. 


practiced  in  the  involvement  of  tlie  upper  end  of  the  ureter  when  annoyance 
from  incurable  fistula  and  from  the  pathologic  processes  at  the  seat  of  the 
injury  becomes  burdensome  to  the  physical  and  mental  welfare  of  the  patient. 
In  injury  of  the  lower  end,  nephrectomy  should  not  be  done  until  after  the 
possibility  of  uretero- vesical  anastomosis  and  other  forms  of  repair  are  dis- 
missed. 

Operative  violence  incident  to  the  treatment  of  surgical  conditions  associ- 
ated with  the  ureter  often  causes  wounds  of  the  tube,  which  are  usually 
either  longitudinal  or  transverse.  The  treatment  of  the  longitudinal  wounds 
is  considered  in  connection  with  calculi  of  the  ureter  (page  807).  The  trans- 
verse wounds,  especially  when  complete,  are  more  difficult  of  treatment  than 
the  longitudinal,  on  account  of  the  gaping  and  the  tendency  to  stenosis.  In 
complete  transverse  wounds  of  the  ureter  the  divided  extremities  should  be 
united  together  (uretero-ureteral  anastomosis),  unless  a  loss  of  substance  of 
the  tube  forbids. 

Uretero-Ureteral  Anastomosis. — Four  methods  of  this  variety  of  repair 
are  considered  : 

1.   Tlie  transverse  end-to-end  luiion  with  and  without  support. 

Tai(fer''s  Method. — In  this  method  the  ends  are  directly  united  together 
with  interrupted  silk  sutures  while  being  supported  by  a  catheter  or  other 


Fig.  104'J.— Uretero-ureteral  anastomosis,  transverse  end-to-end,  with  support. 

Tauffer's  method. 


suitable  agent  introduced  into  the  lumen  (Fig.  1049).  Afterward  the  catheter 
is  withdrawn  through  a  slit  made  preferably  in  the  distal  end  of  the  ureter 
opposite  the  extremity  of  tiie  instrument. 

Schopf.,  Cushing,  and  others  united  the  ends  by  sewing  without  the  aid 
of  support  (Fig.  1050). 


Fig.  1050. — Uretero-ureteral  anastomosis,  transverse  cnd-to-ond,  without  support. 
Schopf,  Cushing,  and  others. 

3.   The  oblique  end-to-end  union  (Bovee)  (Fig.  1051). 

Bovee,  with  the  view  of  preventing  obstruction  at  the  seat  of  union  from 
subsequent  contraction,  divided  the  ends  obliquely,  then  dilated  them  for  an 
inch,  and  united  them  together  by  means  of  alternating  rectangular  and 
interrupted  sutures  of  No.  1  silk  carried  by  a  round  straight  needle  down  to, 
but  not  throuffh  the  mucous  membrane.     The  line  of  union  was  made  addi- 


Oi'I'lRATIONS   ON    VISCKllA    CONNHC'I'KD    WI'I'll    I'llIilTONvEUM.     855 

tioiiiilly  si'ciire  by  four  or  five  interrupted  sutures  su[){)leiiiente(l  by  peritoneal 
iuvcstiiu'iit  at  the  seat  of  the  operation,  so  adjusted  as  to  exclude  from  the 
peritoneal  eavity  the  seat  of  injiiiy. 


Fio.  1051. — rrotiTO-urcterjil  anastomosis,  oblique  end-to-ei)d  union.     Bovoe's  niL-tlioil. 

3.  Invagifuifion,  with  and  icitliout  support,  also  icith  and  without  split- 
ting the  ends. 

Markoe,  in  1897,  in  a  female  patient  invaginated  and  united  over  a 
catheter  the  ends  of  a  ureter  divided  transversely  at  a  point  about  an  inch 
from  the  bladder.  A  No.  9  woven  catheter  was  introduced  into  the  distal  end 
of  the  proximal  part  of  the  ureter,  the  free  extremity  of  the  instrument  being 
carried  outside  of  the  wound.  "  After  careful  isolation  of  the  field  with 
sterile  pads,  two  traction  sutures  were  introduced  close  to  the  severed  end  of 
the  kidney  portion.  The  needles  attached  to  these  threads  were  then  passed 
within  the  lumen  of  the  kidney  stump  and  made  to  emerge  at  two  points 
about  one  sixteenth  of  an  inch  apart  on  the  respective  sites  (Fig.  105"^). 


Fig.  1052. — Uretero-ureteral   anastomosis,  end-to-end    invagination,    witli   support,   and 
without  splitting.     Markoe's  method. 

The  free  end  of  the  catheter  occupying  the  renal  stump  was  then  passed 
into  the  bladder,  caught  by  a  forceps  introduced  into  the  meatus  and  drawn 
down  so  tliat  its  mouth  emerged  into  the  vagina.  The  traction  sutures  were 
then  slowly  tightened,  and  in  this  manner  the  proximal  extremity  invaginated 
for  about  half  an  inch  into  the  lumen  of  the  distal  portion.  After  tying 
the  traction  sutures  a  circular  continuous  suture  completed  the  anastomosis." 
The  line  of  union  was  further  repaired  by  peritonaeum,  the  wound  closed 
except  at  the  lower  part,  tlirough  which  a  gauze  drain,  arising  from  the  seat  of 
the  operation,  escaped.  The  catheter,  which  was  allowed  to  remain  in  place 
for  five  days,  when  removed  was  perfectly  smooth,  having  only  a  few  crystals 
attached  at  the  vesical  end.  For  several  days  a  "  serous  discharge,"  appar- 
ently mixed  with  urine,  escaped.  At  the  end  of  a  month  the  patient  was 
substantially  well. 


856 


OPERATIVE  SURGERY. 


Poggi  practiced  invagination  by  first  dilating  the  distal  end  and  then 
drawing  the  proximal  extremity  into  it  by  means  of  one  or  more  traction 
sutures  (Fig.  1053),  which  were  then  tied. 


Fig.  1053. — Uretero-ureteral  anastomosis,  end-to-eiid  invagination,  without  support  and 
without  splitting.     Poggi"s  method. 

Rohso7i  and  Winslow  attained  their  aim  by  first  slitting  up  for  a  short 
distance  the  open  end  of  the  distal  part  of  the  ureter,  causing  invagination 
and  union  of  the  proximal  end  by  traction  sutures  (Fig.  1054),  the  same  as 
in  the  preceding  method.  The  slit  at  the  side  was  closed  over  the  invagi- 
nated  extremity  with  sutures.  In  neither  of  the  last  two  instances  was  inter- 
nal support  employed,  and  in  both  additional  security  is  given  by  sewing  the 
free  ends  of  the  outer  to  the  contiguous  walls  of  the  invaginated  portions. 


Fig.  1054. 


-Uretero-ureteral. anastomosis,  end-to-end  invagination,  without  support  and 
with  splitting.     Robson-Winslow  method. 


4.  Lateral  rmphrntation  (Van  Hook). — The  method  by  lateral  implanta- 
tion, as  announced  by  Van  Hook  in  1S93,  is  practiced  as  follows:  Ligature 
the  distal  portion  of  the  ureter  at  a  point  an  eighth  or  a  quarter  of  an  inch 
from  the  end  with  silk  or  catgut ;  beginning  a  quarter  of  an  inch  below  the 
ligature,  make  an  incision  into  the  lumen  twice  as  long  as  the  diameter  of 
the  ureter  with  a  fine,  sharp-pointed  scissors;  make  an  incision  from  the  open 
end  of  the  proximal  part  upward  a  quarter  of  an  inch  (Fig.  1055,  a) ;  pass 
from  within  outward  through  the  upper  wall  of  the  ureter,  an  eighth  of  an 
inch  from  the  end,  two  very  small  cambric  needles  introduced  an  eighth  or 
sixteenth  of  an  inch  apart  and  armed  with  a  single  suture  of  catgut ;  carry 
the  needles  through  the  slit  into  the  tube  for  half  an  inch,  thence  out 
through  the  wall  side  by  side  (Fig.  1055,  h) ;  remove  the  needles  and  then 
make  traction  on  the  extremities  of  the  suture,  thus  drawing  the  upper  end 
of  the  ureter  snugly  into  the  lower  portion,  and  tie  the  suture  securely  (Fig. 


urERATIONS   ON    VISCERA   CONNECTED   WITH    I'ERITON JX'.M.     857 

1055,  c,fl)\  surround  the  seat  of  operation  carefully  with  peritonaium  if  tlie 
wound  be  iutraperitonoal. 


Fig.  1055. — Uretero-ureteral  anastomosis,  end-in-side  implantation.    Van  Hook's  method. 

Emmefs  Modification. — In  certain  instances  the  proximal  end  of  the 
tube  is  permanently  stretched  from  the  over-distention  incident  to  accumu- 
lation of  fluids  dependent  on  tumor  pressure,  calculi,  etc.  In  these  cases 
ready  implantation  requires  that  tlie  end  be  diminished  in  size,  often  to  a 


Fi(i.  1056. — Uretero-ureteral  anastomosis,  end-in-side  implantation.     Emmet's  method. 

considerable  degree.     Emmet  attained  the  object  by  means  of  three  short 
sutures  introduced  at  different  aspects  of  the  dilated  end.     The  manner  of 


OPERATIVE   SURGERY. 


tlie  introduction  and  of  the  aeconipliihnient  of  the  purpose  is  sufficiently 
well  indicated  by  the  illustrations  (Figs.  105G  and  lOoT). 

Kelly  and  Bloodgood  modified  somewhat  the  manner  of  the  introduction 
of  the  traction  sutures,  and  added  secondary  sutures  to  the  line  of  union. 

Two  needles,  each  armed  with  a  black 
silk  suture,  were  introduced  through 
the  longitudinal  incision  into  the  lumen 
and  carried  thence  outward  respectively 
one  through  each  lateral  wall  (Fig. 
1058).  As  each  suture  had  already 
been  passed  respectively  through  the 
outer  wall  of  the  proximal  end,  traction 
made  upon  them  caused  this  extremity 
to  enter  the  lower  through  the  longi- 
tudinal slit,  where  it  was  fixed  by  tying 
the  sutures.  "  Two  additional  sutures 
were  passed  through  the  lateral  walls 
where  the  ends  overlapped,"  thus  com- 
pleting the  anastomosis.  EelJy  prac- 
ticed the  plan  successfully  on  the  hu- 
man subject,  and  Bloodgood  demon- 
strated it  later  on  the  dog.  On  the  re- 
moval of  the  ureter  from  the  dog  at  the 
end  of  three  months,  an  interesting 
outcome  was  ascertained  (Fig.  1059).  The  mucous  membrane  was  con- 
tinuous and  no  stricture  was  present. 

The  Results. — First  class :  12  operations  with  2  deaths,  neither  of  which 
was  dependent  on  the  ureteral  procedure.     Second  class :  1  operation,  en- 


1057. — Uretero-ureteral  anastomosis. 
Emmet's  method  completed. 


Fig.  1058. — Uretero-ureteral  anastomosis,  end-in-side.      Kelly  and  Bloodtrood's  method. 

tirely  successful.     Third  class  :  9  operations  with  1  death.     Fourth  class :  5 
operations  with  1  death  (Bovee). 


Fig.  1059. — Uretero-ureteral  anastomosis.     Result  in  Kelly  and  Bloodgood's  method. 

The  Choice  of  Operation. — As  yet  one  can  not  judge  consistently  of  the 
comparative  value   of  the  various  methods  because  of  limited  experience. 


OPKKATIUNS   ON    VISCERA    C'OXXKCTHD   Wmi    I'KKITOX JIL'.M.     ^^g 


However,  the  best  operation  is  the  one  tli.it  is  most  avaihible  and  least  liable 
to  troublesome  ser|uels.  The  transverse  end-to-end  methods  appear  to  be 
more  liable  to  leakage  and  stricture  than  do  the  others.  The  end-in-end 
plans,  while  less  liable  to  leakage  and  stricture  than  the  former,  do  not  seem 
to  be  as  exempt  from  these  inlirmities  as  the  method  of  Win  Hook,  and  its 
modifications.  In  instances  of  complete  division  with  much  dilatation, 
liovee's  method,  aitliough  somewhat  tedious  and  exacting  in  its  teclmique, 
and  apparently  more  prone  to  leakage  than  are  the  invagination  methods, 
nevertheless  is  commendal)le  and  should  be  comparatively  free  from  stricture 
sequels.  In  the  presence  of  comi)lete  division  with  limited  dilatation  and  also 
of  a  normal  ureter,  Van  Hook''s  method  is  simple,  expeditious,  and  effective. 
The  employment  of  internal  support  in  the  technique,  wliile  affording  tem- 
porary aid,  complicates  the  pro- 
cedure to  a  degree  not  justified  by 
the  comparative  results  of  methods. 
About  an  inch  of  the  ureter  is  re- 
quired for  end-in-end  (invagina- 
tion) anastomosis,  and  an  inch  and 
a  half  for  end-in-side  union. 

Implantation  of  the  Ureter. — 
When  loss  of  substance  luis  at- 
tended division  of  the  ureter  ren- 
dering approximation  and  union 
of  the  ends  impossible,  implanta- 
tion of  the  proximal  part  into  the 
bladder,  the  large  intestine,  the 
ureter,  or  upon  the  skin  becomes 
necessary.  The  caecal,  sigmoid, 
rectal,  etc.,  are  the  subdivisions  of 
implantation  into  the  large  intes- 
tine. The  implantation  of  one 
into  the  opposite  ureter  is  an  avail- 
able plan  of  practice.  The  graft- 
ing into  the  pelvis  of  one  kidney 
of  the  ureter  of  the  opposite  kid- 
ney may  prove  serviceable  in  some 
instances.  The  connection  of  the 
ureter  with  the  vagina  or  urethra 
can  not  be  favorably  regarded  ex- 
cept when  other  avenues  of  suc- 
cessful effort  are  closed. 

The  Implantation  into  the  Blad- 
der (Ureterocystostomy).  —  The 
grafting  of  the  ureter  into  the  bladder  is  easier  of  performance  than  splicing 
the  ureter  (Fig.  1060).  This  variety  of  implantation  may  be  either  extra- 
peritoneal or  intraperitoneal.  The  extraperitoneal  method  was  performed 
by  Baumm^  as  follows: 


y 


Fig.  1060. — The  implantation  of  the  ureter  into 
the  bhulder,  Kelly's  method.  «.  Ureter 
drawn  through  opening  in  bladder  by  for- 
ceps passed  through  urethra,  h.  One  su- 
ture introduced  holding  urethra  in  place, 
c.  Ureter  secured  in  place  by  deep  and  su- 
perficial sutures. 


8(50  OPERATIVE   SURGERY. 

The  patient  iu  question,  a  female,  had  a  double  ureter  on  the  riglit  side, 
one  of  which  terminated  at  tlie  mouth  of  the  urethra  causing  dribbling  of 
urine.  Through  a  suprapubic  incision  Baumm  made  a  small  opening  into 
the  base  of  the  bladder,  caught  and  severed  the  abnormal  ureter,  implanted 
the  proximal  end  into  the  opening  at  the  base,  and  tied  the  distal  one.  He 
regards  the  vaginal  route  the  better  one  in  such  cases,  but  employed  this 
because  of  the  virginity  of  the  patient. 

WetzeVs  Method. —  Wetzel,  in  a  case  of  uretero-vaginal  fistula,  opened  the 
abdomen,  found  the  ureter  at  the  brim  of  the  pelvis,  exposed  and  divided  it 
near  the  middle  of  the  broad  ligament,  closed  the  lower  end  with  sutures 
and  returned  it  to  the  pelvis,  brought  the  kidney  end  into  the  upper  part 
of  the  incision  at  the  brim  of  the  pelvis  and  carried  it  under  the  peritonseum 
by  means  of  long  forceps  introduced  beneath  this  membrane  at  the  right  of 
the  bladder,  closed  the  pelvic  and  abdominal  incisions  of  the  peritonaeum, 
thus  excluding  the  field  of  operation  from  the  abdominal  cavity.  The 
bladder  was  then  pl^lled  so  as  to  extend  an  inch  and  a  half  to  the  right  of 
the  end  of  the  ureter  and  there  the  structures  were  joined  together  by  sew- 
ing. An  oblique  incision  of  the  bladder  was  made  down. to  the  mucous 
membrane,  the  end  of  the  ureter  divided  obliquely,  and  the  borders  of  its 
mucosa  sewed  to  those  of  an  opening  made  iu  the  mucous  lining  of  the 
bladder  by  cutting  upon  the  end  of  a  forceps  carried  upward  through  the 
urethra  to  the  inner  aspect  of  the  oblique  incision.  The  walls  of  the  ureter 
were  then  united  to  the  borders  of  the  bladder  incision,  and  the  oblique 
channel  was  completed  by  suturing  the  bladder  structures  over  the  ureter. 
The  organ  was  drained  for  four  days  through  an  independent  opening.  The 
recovery  of  the  patient  was  satisfactory. 

Intraperitoneal  implantation,  according  to  Fenger,  was  practiced  suc- 
cessfully by  Xovaro,  in  1893,  for  the  relief  of  a  patient  with  uretero-vaginal 
fistula  following  a  vaginal  hysterectomy  performed  for  carcinoma  extending 
into  the  broad  ligament.  Two  months  later  a  laparotomy  was  made  with 
the  patient  in  the  Trendelenburg  position,  the  ureter  dissected  from  the 
vagina,  slit  upward  for  two  fifths  of  an  inch,  unfolded,  and  united  to  an 
incision  in  the  bladder  three  fifths  of  an  inch  long,  and  located  about  an 
inch  and  a  half  above  the  normal  insertion.  The  gauze  drainage  introduced 
into  the  wound  was  impregnated  for  several  days  with  the  urine  that  escaped 
from  the  defective  union.  In  ten  days,  however,  repair  had  taken  place,  and 
the  functions  of  the  parts  were  permanently  restored.  Krug,  who  divided 
the  ureter  during  the  removal  of  a  fibrous  tumor,  clamped  the  divided  ends, 
and  completed  the  operation.  He  then  made  an  incision  into  the  bladder, 
treated  the  end  of  the  ureter  as  done  by  Van  Hook  for  invagination,  intro- 
duced it  into  the  bladder  incision  and  sewed  it  there,  being  careful  not  to 
obstruct  the  lumen.  Several  tiers  of  running  sutures  were  made  and  the 
available  amount  of  peritonaeum  employed  "  to  build  a  solid  wall "  around 
the  ureter.  A  catheter  was  kept  permanently  in  the  bladder  for  four  days, 
after  which  catheterization  was  practiced  every  four  hours.  The  patient 
recovered  promptly  without  an  untoward  symptom,  and  left  the  hospital  in 
four  weeks. 


oi'KKA'rioN'S   ()\    VISCKRA   (M)NNK("rHI)   WITH    I>KKITONyEUM.     801 

l\'uro,se  removed  an  inch  of  tlie  ureter  vvliich  was  involved  in  a  carcinoma 
of  tlie  cervix,  lifjatured  the  distal  and  implanted  the  proximal  end  into  the 
bladder  by  Van  Hook's  method,  and  closed  the  abdomen  without  drainage. 
The  patient  made  a  good  recovery. 

Kelhj  quotes  a  case,  happening  in  the  practice  of  Fullerton,  of  division  of 
double  ureter  during  the  removal  of  the  uterine  appendages.  In  this  instance 
the  vesical  ends  were  ligatured  and  the  others  introduced  side  by  side  into  an 
opening  made  into  the  bladder  at  the  su])erior  portion  and  a  little  to  the 
right,  and  sutured.     This  patient  made  a  prompt  and  uneventful  recovery. 

Baldwin^  who  lately  excised  an  inch  and  a  half  of  the  ureter  in  perform- 
ing hysterectomy,  was  obliged,  because  of  the  loss  of  this  amount,  to  implant 
the  ureter  into  the  bladder.  In  order  to  relieve  the  undue  traction  thus 
created,  the  wall  of  the  bladder  at  the  point  of  implantation  was  sutured  to 
the  stump  of  tlie  broad  ligament.     This  patient  recovered. 

The  manner  of  implantation  is  a  matter  of  great  significance.  The  pro- 
curing of  secure  union,  the  prevention  of  constriction  and  of  regurgitation 
from  the  bladder  are  important  desiderata.  The  employment  of  aseptic  care 
and  the  prevention  of  traction  at  the  seat  of  grafting  meet  the  first  require- 
ment. The  raising  of  the  bladder  higher  in  the  pelvis,  and  fastening  it  in 
place  by  suturing  to  the  broad  ligament  or  to  other  convenient  structures,  is 
a  well-directed  effort  for  the  prevention  of  traction.  Traction  sutures, 
attached  to  the  intravesical  end  of  the  ureter  and  passed  out  through  the 
urethra  and  fastened  to  the  dressings  or  held  by  weighting,  are  employed 
with  success  to  neutralize  the  influence  of  the  upward  traction  on  the  im- 
planted end  of  the  tube.  The  encroachment  on  the  line  of  repair  of  drain- 
age agents  is  objectionable,  and  should  not  be  permitted  when  possible  to 
avoid  it.  Drainage  should  not  be  employed  in  any  instance,  unless  it  is 
deemed  as  very  essential.  The  splitting  of  the  implanted  end  of  the  ureter, 
and  the  oblique  introduction  of  the  same  through  the  bladder  wall,  are  em- 
ployed to  prevent  constriction  and  return  flow  respectively.  The  implanta- 
tion together  of  the  ends  of  the  ureters  and  the  intimate  bladder  wall  into 
the  bowel  is  a  matter  of  brilliant  conception  and  successful  attainment  (page 
1154).  Implantation  may  be  accomplished  quite  readily,  in  some  instances, 
by  bringing  the  end  of  the  ureter  and  the  portion  of  the  bladder  into  which 
grafting  is  to  be  made  outside  of  the  abdominal  cavity. 

The  Remarks. — The  abdominal  route  is  preferable  in  all  instances  of 
nreterocystostomy,  and  especially  in  operative  injuries  of  the  ureter,  as  then 
the  repair  can  be  made  before  closure  of  the  abdominal  incision.  Extraperi- 
toneal is  preferable  to  intraperitoneal  implantation.  However,  in  the  latter 
plan  the  peritonaeum  is  closed  around  the  wound  so  carefully  as  to  constitute 
in  effect  extraperitoneal  implantation,  so  far  as  the  wound  is  concerned.  If 
the  peritonaeum  be  drawn  too  closely  around  the  ureter  at  the  site  of  implan- 
tation, constriction  of  the  tube  may  follow  (Martin).  Ureteral  fistulae  of 
congenital  or  acquired  nature  are  sometimes  treated  by  implantation  made 
through  the  vagina,  which  affords  a  difficult  and  constricted  field  of  action. 
Whenever  diseased  products  are  associated  with  the  operation  field,  the  intra- 
peritoneal method  should,  if  possible,  be  avoided. 


862 


OPERATIVE   SURGERY. 


IVie  Results. — Bovee  reports  37  iireterocystostomies  for  injury,  15  by  the 
intniperitoneMl  and  2  by  the  extraperitoneal  methods,  the  remainder  not 
stated.  In  12  of  the  former  cases  resection  of  the  bhidder  was  done.  The 
mortality  was  a  little  over  2  per  cent.  Also  42  iireterocystostomies  for 
various  kinds  of  fistulae,  etc.,  are  reported.  Of  these,  12  were  intraperitoneal, 
14  extraperitoneal,  and  16  unstated.  Four  died,  of  which  2  succumbed  to 
kidney  complications  at  a  later  period. 

The  Implantation  into  the  Bowel. — The  technical  difficulties  of  bowel 
implantation  of  the  ureter  are  miic.li  less  serious  than  tlic  resultant  infection 
of  tlie  kidney,  which  appears  so  likely  to  follow  from  the  wanderings  of  the 
intestinal  microbes.  Experimentally  the  technique  is  successful,  but  practi- 
cally the  outcome  was  so  frequently  fatal  in  animals  as  to  discourage  for  a 
while  the  attemi)t  in  man.  Axial  im})lantation  of  the  ureter  into  the  bowel, 
and  its  retention  there  by  sutures ;  implantation  of  both  ureters  with  a  small 
associated  piece  of  bladder  wall  (page  1154) ;  and  implantation  of  the  ureters 
with  associated  mucous  membrane,  are  the  methods  of  practice  commonly 
employed. 

Chaput  implanted  the  ureter  into  the  colon  for  relief  of  a  uretero-vaginal 
fistula  following  vaginal  extirpation  of  the  uterus.  Through  an  abdominal 
incision  he  exposed  and  isolated  the  ureter,  divided  it  transversely,  ligatured 
the  vesical  end,  and  implanted  the  renal  end  by  two  rows  of  sutures  into  the 
colon.  The  patient  voided,  three  or  four  times  pei'  diem,  mixed  urine  and 
ffeces,  and  was  satisfied  with  her  condition.  No  signs  of  infection  of  the 
kidney  were  present  five  months  after  the  operation.  In  another  case,  a  few 
months  later,  a  fatal  result  followed. 

Martiti's  Method  (Axial  Implantation).  —  The  mechanism  of  this 
method  is  substantially  as  follows :  1.  The  ureters  are  caused  to  so  empty 
into  the  bowel  in  its  long  diameter  that  the  urine  and  fa?ces  are  dis- 
charged in  the  same 
direction.  2.  The 
longitudinal  burying 
for  an  inch  or  more 
of  the  ureters  in  the 
wall  of  the  rectum 
permits  the  pressure 
of  the  outgoing  f;T?cal 
matter  on  the  mucous 
membrane  to  empty 
and  compress  the 
lower  extremities  of 
the  ureters.  The  mus- 
cular contractions  of 
the  gut  contribute 
their  influence  to 
these  results. 
The  Operation. — Cleanse  the  bowel  thoroughly  and  place  the  patient  in 
the  Trendelenburg  position ;  expose  the  rectum  through  an  abdominal  inci- 


Fiu.  1061. — Implantation  of  the  ureters  into  the  bowel,  ^Mar- 
tin's  method,  a.  The  rectum,  b.  Point  of  constriction  of 
the  bowel,  c,  c.  Ureters  joined  together  in  parallel  posi- 
tion. d,d,d.  Silk  suture  armed  with  needles  attached  to 
the  ureters  and  passing;  into  a!id  out  through  the  wall  of 
the  bowel,  e.  e.  Traction  sutures  for  drawing  apart  the 
borders  of  the  wound.  /.  Muscular  fibers  of  the  bowel. 
g.  Opening  for  the  passage  of  sutures,  h.  Points  of  escape 
of  ends  of  traction  sutures. 


()1m:ka'I'1().\s  on  visckk'a  connec'I'kd  wrrii  im;im'I'()Nm;i:m.    s<;;'> 

sioii ;  iiaisi'  tlu-  pcrituMa-uiii  over  the  lower  tliree  or  four  inches  of  the  ureters 
down  to  the  bhidder ;  dissect  out  the  lower  three  inches  of  the  ureters  and  tie 
each  with  a  strong  ligature  near  to  the  bladder,  severing  them  close  above  the 
ligatures  (Fig.  lO(Jl) ;  bring  tlie  renal  extremities  of  the  ureters  forward  and 
join  them  together  in  a  parallel  jjosition  {r,  c)  by  passing  through  their  outer 
walls  a  long,  tine  silk  suture  armed  at  each  end  with  a  cambric  needle;  make 
a  two-inch  longitudinal  incision  at  the  uppermost  part  of  the  wall  of  the 
rectum  down  upon  its  muscular  coat;  expose  by  dissection  an  oval  surface 
an  inch  in  width  at  its  greatest  transverse  diameter,  drawing  apart  the  (laps 
witli  traction  loo])s  {<;  e);  close  the  bowel  above  the  incision  with  a  clamp  or 
other  suitable  means  (b) ;  make  an  incision  into  the  bowel  at  a  point  of  the 
oval  space  ( /")  tliree  fourths  of  an  inch  from  the  lower  end  (g),  large  enough 
to  admit  the  ends  of  the  ureters;  pass  downward  through  the  opening  (g) 
the  doubly  armed  ligature 
(d,   d,   d),    causing    the  ^^"^^.x 

needles  to  escape  anteri-    ~-  '  ''' 

orly  about  an  inch  below 
the  place  of  entrance  {h) ; 
draw  the  ureters  througli 


¥..  ^:-^EE^;;*/^ 


]^ 


the     opening     into     the  /,  ^^/        ""*'''»""""' '  iiiii**'"^"*-**-'^--^ 

bowel   as  far  as  the  su-  «i*s*^  ^ 

tures  will  permit  (Fig.  Fig.  1062.— Implantation  of  the  ureters  into  the  bowel, 
infi9\       Vh:>vjto   the  111-0  Martin's  method,     a.  The  rectum,     b.  Point  of  con- 

lUD^;.      r.it\aie   tne  uie-  striction  of  tlie  bowel,     c. c.  The  ureters,     e,  e.  Union 

ters  {c,  c)  to  a  right  angle  of  peritoneal  borders,     h.  Traction  sutures  tied, 

with    the   bowel,  uniting 

them  low  down  to  its  libro-muscular  coats  by  fine  catgut  sutures  so  passed 
as  not  to  invade  the  cavity  of  the  gut  or  constrict  the  lumen  of  the  tubes ; 
place  the  ureters  on  the  denuded  surface  parallel  with  the  bowel,  and  unite 
them  at  either  side  to  the  muscular  coats  of  the  intestine;  infold  the  mus- 
cular coats  by  uniting  them  together  with  fine  silk,  thus  burying  the  ex- 
tremities of  the  ureters  the  distance  of  an  inch ;  cover  in  the  wound  up  to 
the  bifurcation  of  the  ureters,  uniting  the  divided  peritoneal  borders  with 
fine  silk  {e,  e) ;  increase  the  security  of  the  implantation  by  additional  fine 
silk  sutures  where  needed.  The  abdominal  wound  is  then  closed,  leaving 
sufficient  room  at  the  lower  angle  for  the  escape  of  a  small  gauze  draiii 
extending  out  from  the  seat  of  implantation. 

The  Remarks. — The  renal  portions  of  the  ureters  should  be  controlled 
from  the  outset  by  pressure  to  prevent  the  escape  of  fluids.  This  method  of 
practice  has  been  applied  both  to  dogs  (thirty-eight)  and  human  subjects 
(three) ;  to  the  latter  in  one  instance  of  removal  of  the  bladder,  and  in 
another  for  exstrophy  ;  the  third  is  not  stated. 

The  Results. — In  the  case  of  cystectomy  the  patient  lived  three  years.  In 
the  case  of  exstrophy  the  implantation  was  only  a  partial  success.  Of  the 
dogs,  4:  lived  an  "  indefinite  time,"  in  2  of  which  both  ureters  were  implanted 
in  the  rectum. 

Fowler's  Operation. — Fowler  aimed  to  supplement  the  restraining  influ- 
ence of  the  circular  fibers  of  the  gut  on  the  lumen  of  the  ureter,  during  defe- 


864 


OPERATIVE  SURCxERY. 


cation,  with  a  valve  of  mucous  membrane  so  arranged  as  to  provide  greater 
security  against  ascending  infection  then  and  during  the  presence  in  the 
bowel  of  excrementitious  substances. 

The  Operation. — Thoroughly  cleanse  the  bowel  and  dilate 
the  anal  sphincters ;  place  the  patient  in  the  Trendelenburg 
position  and  open  the  abdomen  in  the  median  line ;  draw 
aside  the  intestines  and  identify  the  ureters  and  their  rela- 
tions with  the  vessels ;  incise  the  peritonaeum ;  expose  and 
trace  the  ureters  to  the  bladder  wall ;  sever  the  ureters  on  a 
line  with  the  bladder  wall  and  cut  the  proximal  ends 
obliquely  (Fig.  1063) ;  make  a  longitudinal  incision  in  the 
anterior  wall  of  the  rectum,  through  the  serous  and  muscu- 
lar coats,  two  and  three  fourths  inches  long;  dissect  care- 
fully aside  these  tissues,  exposing  a  diamond-shaped  submu- 
cous space  (Fig.  10G4) ;  introduce  traction  loops  and  draw 
apart  the  borders  of  the  wound ;  cut  in  the  mucous  mem- 
Implantation  of  brane,  at  the  lower  half  of  the  field,  a  tongue-shaped  flap 

the  ureters  in-   ^^jj^^j^  ^jjg  ^^g^gg  vipward  :    double  upward   the  tongue-shaped 
to   the    bowel  .  .  . 

Fowlers meth-   Aap  ou  itself,  SO  that  its  apex  will  correspond  to  its  base; 

od.       Oblique  join  the   halves  together  in  this  position  with  a  suture  at 

ureter     **  ^'^^h    side,  thus   forming   a  flap    with  a  double   surface  of 

mucous  membrane ;  place  the  ureters  side  by  side  upon  the 

flap,  with  their  ol)liquely  cut  surfaces  undermost  (Fig.  1005)  ;  secure  the 

ureters  in  position  with  sutures,  being  careful  that  they  do  not  invade  the 


Fig.  1063. 


Fig.  1064. — Implantation  of  the  ureters 
into  the  bowel,  Fowler's  method. 
The  tongue-shaped  mucous  flap. 


Fig.  1065. — Implantation  of  the  ureters  into 
the  bowel,  Fowler's  method.  The  mu- 
cous flap  attached  to  the  ureters. 


lumen  of  the  tubes ;  push  the  valve  and  the  attached  ends  of  the  ureters 
into  the  rectum,  and  close  the  rectal  wound  as  follows :  close  the  gap  in  the 


<)I'EI{A'ri(»NS  ON   VlSCi:i{A   ("ONNKCTKD   WITH    l'i:i;ri'(»N .KIM.     sr.:, 

membrane  left  by  tlie  rellectiHl  llap  willi  cat<,'iit  sutures  (Fig.  KxiC);  close 
the  wound  of  the  sero-muscular  coats  with  silk  sutures,  causing  one  or  two 
in  their  passage  to  include  the  wall  (not  the  lumen)  of  the  ureters  for  beticr 
security  (Fig.  lOG^);  unite  the  abdominal  wound  and  place  the  patient  in 
bed. 

Fotder  claims  the  following  advantages  for  this  method,  which,  it  seems 
to  us,  the  history  of  the  case  in  (piestion  justifies:  1.  "An  etticient  perma- 


Fio.  1066. — Implantation  of  the  nreters 
into  the  bowel.  Fowler's  method. 
Gap  in  mucous  meuibrane  closed. 


Fir:.  1067. — Implantation  of  the  ureter  into 
the  bowel.  Fowler's  method.  Sero- 
muscular coats  united. 


nent  valve,  with  a  mucous  surface  applied  to  the  open  mouths  of  the  ureters, 
is  provided.  This  valve  is  so  situated  that  it  is  closely  applied  to  and  occludes 
the  open  ends  of  the  ureters  as  the  rectum  becomes  filled  with  urine,  or  when 
faecal  matter  descends." 

2.  "  The  placing  of  the  ureters  in  the  submucous  space  of  the  rectal  wall, 
for  a  distance  of  three  or  more  centimetres  (an  inch  and  a  quarter  or  more) 
above  the  point  where  they  enter  the  cavity  of  the  rectum,  affords  an  addi- 
tional safeguard  against  renal  infection.  In  this  situation  the  circular  mus- 
cular fibers  of  the  bowel  wall  compress  the  ureters  and  secure  occlusion  at 
this  point  during  defecation." 

Knjn.ski  exposed  the  submucous  tissue  of  the  rectum,  introduced  the 
ends  of  the  ureters  into  the  rectum,  and  closed  the  wound,  fastening  the 
ureters  in  place. 

Mdi/dl  transplants  the  ureters  with  an  elliptical  piece  of  the  trigone  of 
the  bladder  (page  1154)  to  the  bowel,  thus  preserving  the  natural  mechanism 
of  the  ureteral  openings.  This  method  of  practice,  which  certainly  is  more 
complicated  than  either  Fowler's  or  Martin's  methods,  is  commended  by  the 
outcome  that  seems  to  follow  its  employment. 


866  OPERATIVE   SURGERY. 

VignoNi,  Pisa)/)',  and  many  others  have  devised  ingenious  phms  of  action, 
but  it  seems  to  us  that  those  already  expressed  in  detail  are  better  suited  to 
the  purpose. 

The  measures  of  Oersnny,  Maudaire,  and  Tizzoni,  directed  to  division 
of  the  bowel,  with  the  idea  of  establishing  an  independent  delivery  of  the 
excretory  products,  do  not  require  special  consideration. 

The  EesiiUs. — Bowel  implantation  has  been  performed  65  times  on  man, 
with  a  mortality  of  18 :  6  died  promptly  from  shock ;  7  lived  from  five  days 
to  two  3'ears,  dying  from  infection  of  the  kidney  or  other  consequent  com- 
plications.    The  causes  of  death  of  the  remaining  5  are  obscure. 

The  Implantation  on  the  Skin. — Implantation  on  the  skin  will  quite 
likely  be  followed  sooner  or  later  by  kidney  infection.  Yet,  while  this  is 
true,  the  disease  of  a  kidney  may  be  so  extensive  as  to  favor  its  employment 
in  lieu  of  the  more  effective  bowel  implantation.  Implantation  on  the  skin 
can  be  made  through  a  buttonhole  opening  (Pozzi)  in  the  loin  (upper  end), 
or  at  the  seat  of  the  abdominal  wound.  The  technique  of  either  is  com- 
paratively simple.  The  extension  of  the  ureter  through  the  abdominal  cavity 
provides  a  bandlike  structure  that  exposes  the  intestines  to  the  subsequent 
dangers  of  entanglement  and  obstruction. 

In  view  of  the  dangers  of  infection,  and  the  consequent  need  of  a  substi- 
tute for  skin  implantation,  as  previously  considered,  Rydygier  proposed  to 
implant  both  ends  on  the  abdominal  wall  and  establish  a  continuity  of  func- 
tion by  a  plastic  operation,  which  consists  in  turning  over  them  a  flap  of 
skin  so  as  to  provide  for  their  loss  of  substance.  Viui  Hook  proposed  to 
establish  a  diverticulum  from  a  flap  made  at  the  posterior  wall  of  the  blad- 
der, of  sufficient  length  to  properly  join  the  renal  end  of  the  ureter.  While 
these  methods  seem  feasible,  they  lack  the  full  confirmation  of  actual 
practice. 

The  Remarks. — There  is  now  little  need  of  considering  the  availability 
of  skin  implantation.  The  improved  technique  of  bowel  grafting  and  the 
possibility  of  uretero-ureteral  anastomosis,  added  to  the  comparatively  fatal 
outcome  of  the  first,  reduces  its  usefulness  of  application  mainly  to  cases  of 
impending  nephrectomy,  except  in  single  kidneys. 

The  Results. — Bovee  reports  10  cases  of  skin  implantation.  The  rate  of 
mortality  in  those  of  the  number  (6)  with  complete  record  is  about  G7  per 
cent. 

Implantation  info  the  vagina  has  been  practiced  but  3  times,  and  in  each 
instance  with  success.  There  is  but  little,  indeed,  to  commend  the  practice, 
except  for  some  reason  the  unavailability  of  other  and  completer  methods. 

Uretero-tirethral  anastomosis  (Sonnenberg),  or  the  implantation  of  a  ure- 
ter into  the  urethra,  has  been  performed  in  5  instances,  in  4  of  which  the 
cure  of  exstrophy  of  the  bladder  was  the  reason  for  operation. 

The  anastomosis  of  the  ureter  of  one  side  with  its  fellow,  and  even  pos- 
sibly with  the  pelvis  of  the  opposite  kidney,  is  not  an  impossible  accomplish- 
ment, although  of  unestablished  utility.  The  lowering  of  a  kidney  sufficiently 
to  permit  the  joining  of  the  ends  of  a  severed  ureter  may  be  of  service  when 
implantation  implies  greater  danger  than  does  displacement  of  the  kidney. 


OI'KKATIONS   OX   VISCKRA   CONNECTHD    Wmi    I'KlilTONTliUM.     s^T 

Ureteral  Calculus. — ('alculi  are  comnutnly  airt'stcd  at  the  uj)|)or  and 
lower  portions  of  the  ureter.  The  teehiii(iiie  of  the  operation  of  removal  i.s 
modi  (led  by  tlie  situation  of  the  ealeuhus. 

At  the  Lower  Portion  (Vesical). — Calculi  at  this  situation  can  be  removed 
through  the  bJndder^  vagiiKt^  or  rectum.  Calculi  protruding  into  the  bladder 
from  the  ureter,  and  those  near  the  orifice  of  the  ureter,  can  be  removed 
directly  with  or  without  dilatation  of  the  vesical  opening,  through  a  supra- 
pubic incision  of  the  bladder  and  through  the  urethra  directly.  When 
covered  with  mucous  membrane,  the  memljrane  is  excised  and  afterward 
repaired  or  not  by  sewing,  as  seems  best. 

Removal  through  the  Vagi))a. — Emmet  and  Cabot  have  each  demonstrated 
the  feasibility  of  this  plan  of  action  successfully  on  the  living  subject;  both 
patients  recovered.  In  each  instance  an  incision  was  made  through  the 
vagina  upon  the  tumor,  the  calculus  released  and  removed,  and  drainage 
established.  The  incision  should  be  made  toward,  rather  than  from,  the 
neck  of  the  bladder,  to  avoid  division  of  the  fold  of  retrovesical  peritonaeum. 

Bemoval  through  the  rectum  has  been  successfully  performed  by  C!eci. 

At  the  Middle  and  Upper  Portions. — In  either  of  these  portions  of  the 
ureter  an  abdominal  incision  is  necessary  to  reach  the  seat  of  the  obstruction. 
The  incision  is  carried  down  to  [extraperitoneal  ureterotomy)  or  through  the 
peritonreum  {transperitoneal  ureterotomy).,  as  may  seem  needful.  In  the 
former  instance  the  incision  is  made  in  the  iliac  region,  as  for  ligature  of  the 
common  iliac  (Fig.  1T6),  or  in  the  lumbar,  as  in  exploration  of  the  kidney 
(Figs.  1042  and  1044),  as  seems  best  suited  to  reach  the  obstruction.  The 
peritona?um  is  then  reflected  upward  cautiously  with  the  fingers,  with  the 
patient  lying  on  the  opposite  side,  until  the  objective  point  is  reached.  The 
field  of  operation  is  carefully  isolated  to  prevent  infection,  the  ureter  opened 
longitudinally,  and  the  stone  removed. 

In  a  series  of  five  cases,  after  cleansing  the  wound,  the  ureter  was  closed 
with  fine  interrupted  sutures  in  two,  and  left  open  in  three,  instances. 
Proper  drainage  was  provided  in  each  instance.  All  of  the  patients  (five) 
recovered. 

Extraperitoneal  ureterotomy  can  be  performed  after  diagnosis  of  the  na- 
ture and  seat  of  the  obstruction  is  made  through  a  direct  peritoneal  incision, 
which  is  closed  at  once.  TransjJeritoneal  ureterotomy  can  be  performed  in 
those  cases  that  are  intrapelvic,  and  not  amenable  to  approach  by  another 
method.  Two  instances  are  reported  by  Fenger  in  attestation  of  the  worth 
of  the  procedure :  one  died  and  one  recovered. 

The  Iiemarks. — Scrupulous  care  should  be  exercised  to  prevent  infection, 
especially  in  the  cases  characterized  by  pus  collections  at  any  situation,  nota- 
bly at  the  pelvic  portion  of  the  ureter,  and  in  the  presence  of  exposed  serous 
surfaces.  A  stone  at  the  upper  end  of  the  ureter  may  be  displaced  upward 
into  the  pelvis  of  the  kidney  by  manipulation  with  the  fingers  or  needle 
pressure,  and  then  removed.  However,  as  Fenger  very  properly  believes,  this 
attainment  is  not  so  important  if  the  stone  can  be  directly  removed  through 
an  extraperitoneal  incision. 

The  Results  of  removal  of  stone  from  the  ureter  are  3  deaths  in  17  cases. 
61 


868 


OPERATIVE   SURGERY. 


Ureterectomy. — Ureterectomy  is   performed  in  tuberculous  and  suppu- 
rative diseases  of  the  ureters.    The  varieties  of  ureterectomy  are  the  primarily 
where  the  ureter  and  kidney  are  removed  simultaneously;  and  the  secondary, 
where  the  removal  of  the  kidney  precedes  that  of  the  ureter.     In  each  of  the 
foregoing  the  ureter  may  be  partially  or  compleiely  removed  by  either  the 
transperitoneal  or  the  extraperitoneal  route.     The  location  and  length  of 
the  incision  for  exposure  of  the  diseased  structures  varies  according  to  the 
extent  of  the  disease  and  the  route  adopted  for  its  removal.     In  total  extra- 
peritoneal nephro-ureterectomy  the   incision  commended  by  Morris 
(Fig.  1044)  is  suitable.     In  partial  operation  of  this  kind  the 
oblique  incision,  extended  if  necessary  to  the  outer  bor- 
der of  the  rectus  (Fig.  1042,  c),  is  ample.      In  the 
transperitoneal  operation  an    incision  is  made  along 
the  outer  border  of  the  rectus  abdominis  of  suffi- 
cient length  (page  843)  to  permit  of  the  inspec- 
;,      tion  and  removal  of  the  kidney,  and  it  is 
I      extended  thereafter  suitably,  to  afford  ample 
i        r        room  for  examination  and  extirpation  of  the 
diseased  portion  of  the  ureter.    In  partial 
or  total  ureterectomy  the  incisions  of  the 
respective   routes  of   approach  (trans- 
.-a'O"'     peritoneal  and  extraperitoneal)  are 
^V"     *''^=^-.«^'^^"^     made  in  confortnity  with  the  de- 
^-     fi-      --'   vv-    j^^j-j(^|g  Qf   ^\^Q   c^'&Q.      In  the   extra- 
peritoneal   operations   the    peritonaeum 
is  exposed  by  division  of  the  superim- 
posed tissues  along  the  line  of  incision. 
The  peritoufeum  is  carefully  raised  from 
the  overlying  tissues   by   means  of  the 
fingers,  and  reflected  toward  the  median 
line  of  the  body,  until  the  fatty  capsule 
of  the  kidney  or  the  ureter  is  exposed. 
In  the  first  instance  the  kidney  is  cau- 
tiously enucleated  from   its  fatty  envi- 
ronment (page  843)  and   removed,  the 
ureter    remaining    attached.       In    the 
second  instance  the  upper  end  of  the 
fistulous  ureter  is  discovered,  clamped 
and  raised,  and  in  both  instances  the 
ureter  is  carefully  separated  downward 
from  its  immediate  surroundings  to  a 
distance  corresponding  to  the  extent  of 
its  disease.     The  contents  of  the  lumen 
are  then  pushed  upward  with  the  thumb  and  fingers,  and  a  clamp  is  applied 
close  to  the  healthy  part,  around  which  a  ligature  is  tied,  and,  after  careful 
isolation  with  gauze  at  the  latter  point,  the  ureter  is  divided  through  the 
sound  portion  with  scissors,  and  the  diseased  structures  are  removed.     The 


Fig.  1068— Opel. itioii  ot  ioino\iiig  the 
lower  end  of  the  ureter  through 
vaginal  vault,  Kelly's  method.  The 
fingers  of  the  upper  hand  holding 
up  the  uterine  artery  during  per- 
foration of  the  vaginal  vault  by  the 
scissors. 


()IM;KATI()XS   ox    VISCHRA   connected    with    1'EIHT(JN.EL'M.     809 


uretoral  stump  is  then  cauterized  so  as  to  destroy  its  infected  tissue,  and 
dropped  back  into  j)lace.  Tiie  wound  is  wipetl  with  aseptic  cai'c,  and  closed 
entirely,  or  the  lower  end  is  left  ojien  for  the  escape  of  a  small  temporary 
gauze  drain,  when  its  presence  is  required.  Kelly  advises  that,  if  the  kidney 
be  tuberculous,  and  tlic  ureter  be  thus  alTected  in  any  instance,  the  latter 
be  removed,  if  practicable,  tiie  entire  length.  To  properly  accomplish  this 
in  the  female  the  ureter  is  made  taut  by  moderate  traction,  and  its  separa- 
tion is  extended  to  the  brim  of  the  pelvis  by  tlie  lingers,  where  the  iliac 
artery  is  felt.  The  entire  hand  is 
then  introduced  into  the  wound  aiul 
passed  between  the  peritoneum  and 
the  abdominal  wall,  thence  beneath 
the  peritonanim  and  the  wall  of  the 
pelvis,  freeing  the  ureter  down  to 
the  broad  ligament,  which  is  recog- 
nized by  a  sense  of  resistance  and 
the  impression  that  it  seems  to  j)ass 
into  the  broad  ligament,  at  which 
point  the  pulsation  of  the  uterine 
artery  (Fig.  10G8)  is  felt  above.  At 
this  situation  the  ureter  is  caught 
with  forceps,  and  a  stout  ligature 
is  carried  around  it  and  tied,  and 
about  three  quarters  of  an  inch 
more  is  freed  by  means  similar  to 
those  employed  before.  The  con- 
tents of  the  tube  are  then  pushed 
npward,  and  the  tube  clamped  to 
prevent  their  escape  when  the  ureter 
is  divided  just  above  the  ligature 
with  long  scissors  passed  into  the 
wound  from  above.  The  stump  of 
the  ureter  is  now  removed  through 
an  extension  of  the  abdominal  incision,  or  through  the  vagina.  If  by  the 
latter  way,  the  vagina  is  thoroughly  cleansed,  and  the  patient  placed  on  the 
side  opposite  to  the  operation.  The  first  and  second  fingers  of  the  hand 
corresponding  to  the  side  on  which  the  ureter  lies,  are  passed  up  to  the 
vaginal  vault,  and  caused  to  oppose  the  fingers  of  the  opposite  hand  (Fig. 
1068).  The  uterine  artery  is  raised  out  of  the  way  by  a  digit  of  the  inner 
hand  between  the  fingers  of  wdiich  the  ureter  should  lie.  An  assistant  now 
introduces  along  the  fingers  of  the  operator  to  the  vaginal  vault  a  long,  sharp- 
pointed  scissors,  pushing  them  through  the  thin-walled  septum  three  fourths 
of  an  inch  from  the  cervix  into  tlie  abdominal  cavity.  The  scissors  are  with- 
drawn with  the  blades  opened  sufficiently  to  make  an  opening  about  three 
fourths  of  an  inch  in  diameter.  A  long  forceps  is  then  carried  through  the 
opening,  the  ligature  grasped,  the  ureteral  stump  drawn  into  the  vagina,  and 
held  while  the  abdoniinal  wound  is  being  closed  (Fig.  10G9).     The  patient's 


Fig.  1069. — Operation  of  removing  the  lower 
end  of  the  ureter  llirough  vaginal  vault, 
Kelly's  method.  End  of  ureter  exposed. 
Dotted  line  indicates  direction  of  incision 
to  expose  vesical  end  of  ureter. 


870  OPERATIVE  SURGERY. 

condition  permitting,  she  is  placed  in  the  lithotomy  posture,  and  the  vault  of 
the  vagina  exposed  by  retractors,  and  the  cervix  pushed  away  from  the  open- 
ing and  held  by  bullet  forceps.  The  ureter  is  made  tense  by  traction  on  the 
sutures,  and  a  curved  incision  is  formed  in  the  vaginal  vault  from  the  Junc- 
tion of  the  anterior  and  lateral  walls,  forward  and  upward,  beneath  the  base 
of  the  bladder  to  a  point  a  little  more  than  half  an  inch  from  the  vesical 
end  of  the  ureter.  Through  this  incision  the  ureter  is  freed  to  the  vesical 
attachment,  and  ligatured  close  to  the  wall  of  the  bladder,  and  cut  off.  The 
vaginal  wound  is  closed  with  sutures,  leaving  room  for  the  exit  of  a  gauze 
drain  extending  from  the  connective  tissue  above  through  the  opening  into 
the  vagina. 

In  transperitoneal  exposure  of  the  kidney  and  ureter  the  large  and 
small  intestines  are  displaced  toward  the  median  line,  and  the  posterior  peri- 
tonaeum is  divided  at  the  outer  side  of  the  colon,  and  reflected  inward  until 
the  ureter  is  disclosed,  when,  if  the  operation  be  primary,  the  ureter  is  traced 
upward  to  the  kidney,  which  is  enucleated  and  removed  in  the  usual  manner 
(page  843),  leaving  the  ureter  attached.  In  either  primary  or  secondary 
operations  the  ureter  is  separated  from  above  downward  as  far  as  practicable, 
ligatured,  divided,  and  sterilized  the  same  as  before.  The  posterior  peri- 
tona?um  falls  into  proper  position,  therefore  does  not  require  sewing.  The 
abdominal  wound  is  closed  throughout,  except  at  the  jioints  left  for  the 
escape  of  such  drainage  agents  as  may  be  desired. 

The  Precautions. — As  the  ureter  is  made  fragile  by  disease,  only  careful 
traction  on  it  should  be  made,  and  even  this  is  often  attended  with  breaking. 
Prompt  control  of  the  broken  ends  and  thorough  removal  of  the  discharged 
matters  should  be  exercised  at  once,  to  prevent  dissemination  of  infection. 
Before  ligaturing  the  ureter  always  push  aside  its  contents ;  before  dividing 
it,  carefully  protect  the  immediate  tissues  from  possible  infection;  when 
divided  sterilize  the  stumji,  turn  the  end  inward,  and  close  it  with  a  suture. 
It  may  be  necessary  to  ligature  the  uterine  artery  during  the  removal  of  the 
ureter,  because  of  their  intimate  normal  association  (Fig.  173).  The  separa- 
tion of  the  ureter  downward  from  the  iliac  artery  to  the  broad  ligament  is 
difficult  and  comj^licated,  because  of  the  blindness  of  the  procedure  and  the 
proximity  of  important  structures.  In  incising  the  vaginal  vault  carefully 
avoid  the  uterine  artery. 

The  Remarks. — Fenger  considers  pain  in  the  side  as  a  common  sequel 
of  nephrectomy  with  retained  ureter.  The  same  authority  especially  favors 
the  inguinal  incision  and  the  route  along  the  vas  deferens  as  a  guide  to  the 
distal  end  of  the  ureter.  Rectal  distention  raises  the  bladder  and  renders 
the  vesical  portion  easier  of  access.  The  extraperitoneal  is  the  preferable 
route. 

Tlte  BesiiUs. — In  ureterectomy  the  results  are  favorable  indeed  to  life. 
Permanent  fistula  is  a  rare  sequel  of  nephrectomy.  Temporary  fistulfe 
happen  in  from  7  to  25  per  cent  of  the  cases.  Tuberculous  comj^lications 
beget  permanent  fistula. 

The  Relief  of  Valve  Formation. — Valve  formation  at  the  beginning  of 
the  ureter  causes  an  interrupted  and  perhaps  j^ermanent  obstruction  to  the 


oi'KiiAi'ioNs  ()\  visri:i{A  connkc'im:!)  wiiii   I'KIMTON.kum.    871 


^ 


a 


oscapc  (if  iiriiif  from  llu-  pelvis,  followed  by  Uiatcnlioii  of  llie  pelvis  wilh  pus 
ami  urine. 

In  sjx'akiug  of  this  operation,  Fencer  says:  "The   operation  for  valve 
formation  ean    be   best  clone  by  the  extruperitoru'al  lumbar   incision   (Fig. 
104"-i).     Tiie  dilated  pelvis  or 
hydroncphrotio  sac  is  easily 
fouiul,  and    is   opened    by  a 
lonj^itudiiuil    incision.      The 
opening   of   the    ureter    into 
the  sac  should  be  looked  for,     Fjo.   1070.— Opemtinn    for  c-ure  of   valve   fMimafion. 
but  can  not  always  be  found,  Kiistcr- Trendelenburg  method.      a,c.    Wall  of 

"    ■.     •  pelvis   of   kidnev.      h.    Oiienintj  of    ureter   into 

as  m  some    cases  it    is   very  pelvis.  ' 

narrow.       In    such   cases   it 

may  be  located  by  incising  the  ureter  below  the  sac  and  passing  a  probe 
upward  toward  the  pelvis  (Fig.  lOTO).  The  valve  or  inner  wall  of  the 
ureter  running  in  the  sac  is  now  divided  longitudinally  from  the  opening 

in  the  sac,  and  the  resultant 
wound  treated  in  one  of  three 
ways :  («)  Ky  turning  the 
flaps  out  and  uniting  them 
to  the  inner  walls  of  the  sac 
Fiu.  lOTl.-nperatinn  for  cure  of  valve  formation  ^y  sutures  (Kiister,  Trende- 
K<ister- 1  rendelenliurg   method.      o,  r.  Wall   of        -^  ^  ' 

pelvis  of  kidney,  h.  Ureteral  opening  slit  up,  lenburg)  (Fig.  1071)  ;  {h)  by 
flaps  turned  aside  and  stitched  to  the  wall  of  the  drawing  the  corners  of  the 
pelvis.  ,        . 

longitudinal  incision  together 

with  one  suture,  transforming  tlie  longitudinal  into  a  transverse  wound,  as 
in  my  operation;  or  (c;)  by  uniting  the  wound  longitudinally  with  numer- 
ous fine  silk  sutures";  or  by 
"  taking  in  the  two  outer  coats 
of  the  ureter  and  sac,  and  avoid- 
ing the  mucous  membrane " 
(Mynter). 

In  the  first  case  in  question 
Fenger  practiced  the  following 
technique  :  After  exposure  of  the 
kidney  it  was  opened  through 
the  convex  surface  (.r)  with  a 
Paquelin  cautery,  the  opening 
dilated  with  forceps,  and  digital 
palpation  was  made  of  the  pelvis 
and  calices.  Stone  was  not  ^i«-  If^'^.-Operation  for  cure  of  valve  forma- 
tion, Fentrers  method,  a,  a.  Kidnev  with 
found,  nor  could  the  entrance  of  dilated  pelvis,    a^.  Opening  from  nephrotomy, 

the  ureter  be  dilated  bv  tlie  finger  ^-  '>■  filiated  pelvis,     c,  c  Borders  of  open- 

,  rni  ;.   ■  •  /  ins  made  on  posterior  surface,     a.  Opening 

or  probe.     The  posterior  surface  of  ureter  into  pelvis. 

of  the  pelvis  (Fig.  1072,  c,  c)  was 

opened,  and  the  borders  of  the  wound   were    drawn   apart.      At  the  lower 

posterior  portion  of  the  inner  wall  the  opening  of  the  ureter  (d)  could  be 


872 


OPERATIVE   SURGERY. 


Fig.  1073. — Operation  for  cure  of 
valve  formation,  Fenger's  nietli- 
od.  Dilated  pelvis  and  the  ureter. 
a,  a'.  The  pelvis,  b.  The  mucous 
membrane,  c.  The  muscular  and 
external  coats,  d.  The  ureter. 
e.  The  valve.  /.  Line  of  inci- 
sion through  valve. 


seeu.  After  careful  iiis])ection  and  the  introduction  of  a  bougie,  supple- 
mented by  raising  the  pelvis,  it  was  determined  that  the  ureter  was  not  con- 
nected with  the  most  dependent  part  of  the 
wall  of  tlie  dilated  pelvis,  but,  instead,  with 
the  posterior  half,  thereby  causing  the  inner 
lip  of  the  ureteral  opening  to  act  as  a  valve 
and  close  the  aperture  when  fluid  of  "a 
slight  or  medium  amount"  was  present  in 
the  pelvis.  A  greater  degree  of  dilatation 
raised  the  valve  and  permitted  fluid  to 
escape.  In  order  to  overcome  the  valve 
formation,  an  incision  of  about  a  fifth  of 
an  inch  in  length  was  made  vertically 
through  the  inner  lip  of  the  opening  (Fig. 
1073,  e).  The  vertical  incision  was  then 
changed  to  a  horizontal  direction  by  uniting 
the  terminal  points  (Fig.  1074,  a,  a')  with 
fine  silk  sutures.  A  No.  11  French  bougie 
was  readily  inserted  through  the  opening 
down  the  ureter,  and  withdrawn  only  far  enough  to  permit  the  upper  end 
to  protrude  through  the  kidney  wound  (x),  where  it  was  retained  until  the 
wound  had  healed.  The  incision  into  the  pelvis  (c,  c)  was  closed  with  ten 
fine  silk  interrupted  sutures  passed  so  as  not  to  include  the  mucous  lining. 
The  kidney  was  then  returned  and  nephropexy  performed.  The  patient 
recovered  without  a  fistula,  and  was  cured  of  the  cystonephrosis. 

In  the  second  case,  after  isolation  of  the  ureter  from  the  sac  wall  to  per- 
mit the  opening  within  to  be  seen  through  the  pelvic  incision,  a  grooved 
director  was  inserted  into  the  ureteral  opening  from  within,  and  the  portion 
of  sac  wall  that  encroached  on  the  opening  was  resected  all  around,  and  the 
border  of  the  ureter  was  sutured  to  the  divided 
borders  of  the  sac  wall,  thereby  securing  an  ample 
opening  for  a  free  escape  of  fluids  into  the  ureter. 
The  exploratory  opening  was  then  closed,  as  in 
the  preceding  instance,  leaving  a  small  aperture 
for   drainage.      Gauze   was   packed  around   the  ^^ 

tube  down  to  the  opening  in  the  sac.     The  fistula 
closed  on  the  fortieth  day,  and   the  patient  made   Fig.  1074. — Operation  for  cure 

a  cnmnlete  recover v  " ^  ^'''^^'''^  formation,  Fenger's 

a  complete  leCOVeiy.  ^  ^  method.      Valve   seen    from 

Gersier,  in  a  case  of  this  nature  associated 
with  traumatic  hydronephrosis,  approached  the 
kidney  and  upper  end  of  the  ureter  extraperito- 
neally  through  the  oblique  incision.  The  open- 
ing of  the  sac  and  evacuation  of  its  contents  ex- 
posed to  view  the  renal  end  of  the  ureter  sur- 
rounded by  a  C07ie-shaped  pr'ojcction  about  a  tliird  of  an  inch  in  height, 
formed  by  the  eversion  of  the  hyperffimic  and  tliickened  mucous  membrane 
of  the  ureter  (Fig.  1075).     Under   chloroform  anaesthesia  the  rim  of   the 


the  pelvis,  divided  to  illus- 
trate operation,  b.  Ojien- 
ing  of  ureter,  c.  Divided 
valve,  d.  Inner  wall  of  pel- 
vis above  opening  of  ureter. 
a,  a'.  Corners  of  incision  to 
be  untied  by  suture. 


orEliATlO.NS   ON    \1SL'EKA   t'UNN KCTEl)   WITH    I'KKITUN.EL'M.     873 


orifice  was  diviiled  at  either  side,  also  at  the  middle  of  the  upper  border, 
downward,  far  enough  to  sever  the  structures  completely  at  each  line  of 
division  (Fig.  107(!).  The  u})iH'r  and  lower  angles  of  each  incision  were 
united  together  with  catgut  and  the  intervals  closed  transversely  in  a  simi- 
lar manner.  The  lower  portion  of  the  rim  was  then  drawn  downward  by 
the  inlluence  of  the  apposition  of  the  borders  of  an  oval-sha])e(l  dissection 
located  half  an  inch  below  tiie  opening  formed  by  the  removal  of  a  mucous 
Hap  a  tliinl  of  an  incii  wide  and  three  quarters  of  an  inch  long.  Thus  the 
nipple-shaj)ed  structure  was  for  the  time  being  converted  into  a  shallow 
funnel-sliaped     depres-  ^ 

sion.     An  elastic  cath-  / 

eter    was     introduced,  f\ 

but     removed     within  /  \ 

twenty-four   hours   be- 
cause    of     the     i:)ains 

produced   in  the  blad-  ..--""'W  \        >^ 

der  and  penis.     Under 
the  influences  of  proper 


Fig.  1075. — Operation  for 
cure  of  valve  formation, 
Gerster's  method.  Cone- 
shaped  projection  sur- 
rounding renal  end  of 
ureter,  divided  at  tlie 
sides  and  outer  border. 


Fig.  1076. — Operation  for  cure  of  valve  formation,  Ger- 
ster's  method.  Points  of  division,  the  manner  of 
approximation,  and  drawing  down  of  lower  lip  shown. 


cleansing  and  dressing,  the  wound  was  reported  as  healed  five  months 
afterward.  About  eight  mouths  later,  however,  the  wound  reappeared  with 
evidences  of  return  of  the  ureteral  constriction. 

The  Results. — Five  operations  have  been  performed  thus  far,  two  of 
which  (Fenger's  and  ^lynter's)  were  successful. 

Stricture  of  the  Ureter. — Stricture  of  the  upper  abdominal  portion  of 
the  ureter  has  been  treated  successfully  by  the  following  methods : 

Alsbei'g^s  Method. — In  a  case  of  urinary  fistula  following  a  lumbar  nephrot- 
omy for  hydronephrosis,  Alsberg  dilated  from  above  with  fine  bougies  a  stric- 
ture at  the  upper  end  of  the  ureter.  After  several  days  urine  entered  the 
bladder,  and  some  months  later  the  fistula  closed.  The  hydronephrosis  did 
not  recur. 

ICelli/  practiced  successfully  from  below  the  dilatation  of  a  stricture  of 
the  lower  end  of  the  urethra. 

Fe)i(/er''s  Method. — In  a  case  of  nephrotomy  for  increasing  intermittent 
pyonephrosis  of  long  standing,  Fenger,  failing  to  find  the  intrapelvic  open- 
ing of  the  ureter,  raised  the  kidney  out  of  the  wound  and  made  a  longitudi- 


874 


OPERATIVE  SURG  Ell  Y. 


nal  incision  into  the  pelvis,  not  quite  (Fig.  1077)  an  inch  in  length  (.r),  drew 
the  borders  apart,  and  searched  in  vain  for  the  opening  of  the  ureter.  The 
abdominal  wound  was  then  extended  to  within  an  inch  of  the  anterior 
superior  spine  of  the  ilium,  through  which  the  upper  end  of  the  ureter  was 
found  to  be  bandlike  in  appearance,  and  imbedded  for  nearly  half  an  inch  in 
cicatricial  tissue.  A  short  longitudinal  incision,  of  sufficient  length  to  admit 
a  probe,  was  made  into  the  ureter,  at  a  point  about  three  fourths  of  an  inch 
below  its  pelvic  opening,  through  which  a  metal  probe  was  easily  passed 
down  tlie  ureter,  but  upward  it  encountered  obstruction,  because  of  a  nar- 
row stricture  immediately  above.    The  ureter  was  liberated  at  the  constricted 


Fig.  1077. — Operation  for  cure  of  stricture  of  upper 
end  of  ureter,  Penger's  method,  a,  a.  Tlie 
kidney,  x.  Nephrotomy  opening,  b,  h.  Dihxted 
pelvis.  /(.  Ureter  below  stricture.  /.  Stricture 
of  upper  end  of  ureter,  g.  Opening  in  ureter 
below  stricture  and  extending  through  it  into 
the  pelvis,  c,  c,  c,  c.  Sutures  closing  the  upper 
half  of  the  wound  of  the  pelvis,  e,  e'  and  d, 
d' .  Corresponding  points  of  pelvis  and  ureter 
to  be  united  by  sutures  after  folding  the  ureter 
upon  itself  at  the  place  of  stricture. 


Fig.  1078. — Operation  for  cure 
of  stricture  of  upper  end  of 
ureter,  Fenger's  method,  a. 
The  pelvis,  d.  Fold  of  ureter 
at  place  of  stricture.  6,  h' . 
Sutures  of  wound  in  pelvis, 
c.  Place  of  sutures  between 
points  e,  e  and  d.  d'  (Fig. 
1077).  e,  e.  Additional  su- 
tures needful  to  properly  close 
borders  of  fold  formed  liy  ap- 
proximations of  e,  e'  and  d,  d' . 


portion,  and  the  stricture  divided  upward  on  the  probe  as  a  guide.  The 
upper  part  of  the  wotmd  in  the  pelvis  was  independently  closed  with  sutures 
(c,  c  and  c,  c).  The  patency  of  the  tube  was  then  re-established  by  uniting 
the  divided  borders  of  the  wall  of  the  ureter  to  the  corresponding  borders  of 
the  pelvis  (Fig.  1078,  d).  A  large  drainage  tube  was  passed  into  the  upper 
part  of  the  kidney,  and  a  small  one  down  to  the  pelvis  and  ureter.  Gauze 
strips  were  introduced  at  the  anterior  and  posterior  surfaces  of  the  kidney, 
and  for  about  three  inches  around  the  ureter.  The  abdominal  wound  was 
united,  except  at  the  lower  portion,  which  was  kept  open  for  drainage.  The 
patient  made  a  happy  recovery  in  all   respects.     In  another  case   Fenger 


Ol'KKA'l'IONS  ON    VISOKRA   CONNRCTED    WTI'll    I'KKITOX/EUM.     875 


FRONT 


practici'il   lun^itiulinal  ureterutoiuy  at  tlic  upper  t'lid  of  the  ureter,  discov- 
ered and  divided  the  stricture  by  a  longitudinal  incision,  and  repaired  the 

wound    by   joining   to- 


gether  the  upper  and 
lower  ends  wilii  a  su- 
ture, aided  by  folding 
tiie  ureter  on  itself. 
The  patient  was  cured. 
Aforris,  after  care- 
ful exj)loration  of  the 
calices  and  pelvis  for 
stone,  in  a  case  of  cysto- 
nephrosis,  due  to  high 
stricture  of  the  ureter, 
remedied  the  constric- 
tion as  follows  :  He  in- 
troduced a  catheter 
through  a  small  open- 
ing made  into  the  in- 
SIDE  ,  °  ^.,     , 

Fig.  1079.— Operation  for  cure  of  stricture  of  ureter.  Mor-   i^ndibulum,  and  passed 
ris's  case.     A.  Stricture  divided  and  sutures  placed.     B.    the  instrument  through 

^n^rf ''V'''F'ni/"  ^'T''"''^  "^'r^'"/' -  the   stricture   into    the 

sutures.     I.  t^olding  oi  the  ureter  from  tvuig  sutures. 

bladder,  then  divided 
longitudinally  the  strictured  portion  upon  the  catheter.  The  longitudinal 
incision  was  then  converted  into  transverse  union  by  means  of  two  fine 
silk  sutures  (Fig.  10T9),  thus  curing  the  stric- 
ture. Closure  of  the  exploratory  parenchym- 
atous incision,  and  immediate  nephropexy, 
completed  the  operation.  The  wound  healed 
by  first  intention,  and  the  patient  remained 
well  at  last  report.  Stricture  of  the  ureter 
at  a  lower  point  may  be  cured  by  extra- 
peritoneal longitudinal  division,  folding  and 
sewing  as  in  the  preceding  instances  (Fig. 
1080). 

The  Resection  of  the  Ureter  for  Stricture. 
— In  this  procedure  an  inch  or  so  of  the  tube 
is  removed  for  stricture  or  other  reasons, 
and  the  wound  is  repaired  by  restoration  of 
the  continuity  of  the  duct.  Kiister  first 
practiced  the  proposition  in  1891. 

Kusfer\s  Method. — After  a  lumbar  fistula 
and  vesical  anuria,  following  a  lumbo  -  ne- 
phrotomy, had  existed  for  two  years,  Kiister 
secured  patency  of  the  ureter  in  two  months 
by  the  following  plan  :  Failing  to  find  the 
ureter   through   an   extraperitoneal    lumbar 


Fk;.  1080. — Operation  for  cure  of 
stricture  of  ureter,  Fenger's 
method.  A.  Strictured  ureter. 
B.  Stricture  divided.  C.  Ex- 
tremities of  incision  (n  a) 
united.     Ureter  folded  at  d. 


876 


OPERATIVE   SURGERY. 


iucisiou,  he  opened  the  pelvis  of  the  kidney,  disclosed  the  ureteral  orifice, 
and  with  a  probe  located  a  stricture  close  to  it.  lie  divided  the  ureter 
transversely  (Fig.  1081),  just  below  the  stricture  and  at  the  pelvic  entrance, 
and  closed  the  upper  opening  of  the  ureter  and  removed  the  fragment. 
He  then  slit  up  the  ureter  below  at  one  side  for  a  short  distance  (x),  and 
introduced  it  through  an  incision  made  in  the  wall  of  the  pelvis  of  the  kid- 
ney, unfolded  the  end  and  sutured  its  borders  to  those  of  the  opening  in  the 
pelvis  (Fig.  1082),  closing  the  remaining  portion  of  the  latter  with  sutures. 
The  fistula  closed  at  the  end  of  four  montlis  and  the  patient  recovered. 
Several  successful  resections  have  been  rejiorted  since  this  of  Kuster's. 


r 


cA 


Y      V 

I 
L 


Fig.  1081. — Operation  of  resection  of  ureter 
for  cure  of  stricture,  Kuster's  method. 
X.  Indicates  line  of  division  opening 
into  transverse  section  of  ureter. 


Fig.  1082. — Operation  of  resection  of  ureter 
for  cure  of  stricture.  Kuster's  method. 
End  unfolded  and  sewed  to  opening  in 
pelvis  {a,  h.  c). 


Morris  reports  a  case  of  painful  interrupted  hydronephrosis  dependent 
on  oblique  association  of  the  ureter  with  a  diseased  renal  pelvis  (Fig.  1083). 
He  first  laid  freely  open  the  ureter  and  pelvis  by  a  continuous  longitudinal 
incision,  and  stitched  together  the  corresponding  borders  of  the  respective 
parts.  This,  however,  was  not  satisfactory,  and  he  excised  at  once  three 
quarters  of  an  inch  of  the  ureter,  closed  the  greater  part  of  the  pelvic  inci- 
sion, and  sutured  the  end  of  the  ureter  to  the  lowest  part  of  the  sac  (Fig. 
1084),  after  the  manner  of  Kiister  (Fig.  1082).  Then,  fearing  that  the  cali- 
ber of  the  opening  would  be  much  too  small,  and  that  the  unfavorable  con- 
dition of  the  patient  and  the  extreme  thinness  of  the  wall  of  the  ureter  would 
lead  to  chronic  fistula,  the  kidney  was  removed. 

Tlie  Remarks. — Obstruction  of  the  ureter  from  its  abnormal  connection 
with  the  pelvis  of  the  kidney,  because  of  kinking  and  compression  at  the 
pelvis  by  adventitious  products  and  abnormal  arrangement  of  vessels,  is 
noted.  For  relief  of  the  first  cause  of  obstruction,  transplantation  of  the 
ureter  to  a  more  suitable  location  of  the  pelvis,  with  or  without  resection  of 
the  tube,  is  practiced.  For  the  last  two,  division  of  the  constriction,  without 
or  with  resection  and  implantation,  is  practiced. 


Ol'HRATlo.VS   ON    VISCIOIJA    ("ONXKCTKD    Willi    I'KKlToN J:UM.     b77 


Tlie  aiitlior  olTiTs  no  apulugy  for  introducing  at  this  time  the  conclusions 
of  Van  llook-  anil  Feiujir.  'J'iic  logical  results  of  their  tireless  labors, although 
nioililieil  by  subsequent  e.\i)ei'ience  in  many  iiMi)ortant  resj)ects,  can  not  be 


Fig.  1083. — Operation  of  resection  of  up- 
per end  of  ureter,  Morris's  ease.  Show- 
ing opening  into  kidney  substance  and 
into  the  pelvis,  and  oblique  association 
of  ureter  and  dilated  pelvis. 


Fig.  1084. — Operation  of  resection  of  ure- 
ter, Morris's  case.  Side  of  pelvis  sewed 
up  and  ureter  attached  to  dependent 
portion. 


exhibited  too  often  as  an  earnest  of  commendable  outcome  and  a  stimulus  to 
scientific  endeavor. 

Conclusions  of  Van  Hook. — "  1.  The  extrapelvic  portion  of  the  ureter  is 
most  readily  and  safely  accessible  for  exploration  and  surgical  treatment  by 
the  retroperitoneal  route. 

"2.  Hence  all  operations  upon  the  ureters  above  the  crossing  of  the  iliac 
arteries  should  be  performed  retroperitoneally,  except  in  those  cases  in 
which  the  necessity  for  the  ureteral  operation  arises  during  laparotomy. 

"  3.  The  intrapelvic  portion  may  be  reached  by  incision  through  the  ven- 
tral wall,  the  bladder,  the  rectum,  the  vagina  in  the  female,  the  perina?um  in 
the  male,  or  by  Kraske's  sacral  method. 

"  4.  The  ureter  is  not  only  exceptionally  well  protected  from  injury,  but 
by  its  elasticity  and  toughness  resists  violence  to  a  remarkable  degree. 

"5.  The  histology  of  the  ureters  furnishes  most  favorable  conditions  for 
the  healing  of  wounds. 

"  G.  Longitudinal  wounds  of  the  ureter  at  any  point  heal  without  diffi- 
culty, in  the  absence  of  septic  processes,  under  the  influence  of  ample 
drainage. 

"  7.  In  all  injuries  where  the  urine  is  septic  before  the  operation,  or 
where  the  wound  is  infected  during  the  operation,  drainage  must  be 
effected. 

"  8.  The  chemic  composition  and  reaction  of  the  urine  must  be  studied  in 


878  OPERATIVE   SURGERY. 

all  injuries  to  the  ureter,  the  urine  being  rendered  acid,  if  possible,  and  the 
specific  gravity  kept  low. 

"  9.  The  pelvis  of  the  ureter  is,  cmteris  2^((ribus,  the  most  favorable  site 
for  wounds  of  the  ureter,  since  scar  contraction  is  not  so  likely  there  to  be 
productive  of  ill  results. 

"  10.  In  aseptic  longitudinal  wounds  of  the  ureter  occurring  in  the  course 
of  la{)arotomy,  suture  may  be  practiced  and  the  peritonaeum  protected  by 
suture. 

"11.  Transverse  wounds  of  the  ureter  involving  less  than  one  third  of 
the  circumference  of  the  duct  should  be  treated  by  free  drainage  (extraperi- 
toneal) and  not  by  suture. 

"13.  In  transverse  injuries  in  the  continuity  of  the  ureter,  involving 
more  than  one  third  of  the  circumference  of  the  duct,  stricture  by  subse- 
quent scar  contraction  should  be  anticipated  by  converting  the  transverse 
into  a  longitudinal  wound  and  introducing  longitudinal  sutures. 

"13.  In  complete  transverse  wounds  of  the  ureter  at  the  pelvis,  sutures 
may  be  used  if  the  line  of  union  be  made  as  great  as  possible. 

"  14.  In  complete  transverse  injuries  of  the  ureter  in  continuity,  union  must 
not  be  attempted  by  suture. 

"  15.  In  complete  transverse  injuries  of  the  ureter  in  continuity,  union, 
without  subsequent  scar  contraction,  may  be  obtained  by  the  writer's  method 
of  lateral  implantation,  as  described  (Fig.  1055). 

"IG.  In  complete  transverse  injuries  of  the  ureter  very  near  the  bladder, 
the  duct  may  be  implanted,  but  with  less  advantage,  into  the  bladder 
directly. 

"  17.  At  the  pelvis  of  the  ureter  continuity,  after  complete  transverse 
injury,  may  be  restored  by  Kiister's  method  (page  870)  of  suture,  provided 
the  severed  ends  can  be  approximated  by  slightly  loosening  the  ureter  from 
its  attachments. 

"  18.  Rydygierh  method  (page  866)  of  ureteroplasty  in  such  injuries  may 
be  tried  if  other  methods  can  not  be  utilized.  The  primary  operation  should 
at  least  fix  the  ends  of  the  tube  as  nearly  as  possible  together. 

"  19.  In  both  transperitoneal  and  retroperitoneal  operations  the  ureteral 
ends  can  be  approximated  by  my  method  even  after  the  loss  of  about  an  inch 
of  its  substance. 

"20.  The  use  of  tubes  of  glass  and  other  materials  for  the  production  of 
channels  to  do  duty  in  place  of  destroyed  ureteral  substance  must  rarely  be 
satisfactory,  and,  even  if  temporarily  successful,  the  duct  is  almost  sure  to  be 
choked  by  scar  contraction. 

"21.  The  implantation  of  the  cut  ends  of  a  ureter  into  an  isolated 
knuckle  of  bowel  is  objectionable:  (1)  Because  the  bowel  is  not  aseptic;  (2) 
because  the  operation  is  too  dangerous. 

"  22.  In  injuries  of  the  portion  of  the  ureter  within  the  pelvis,  with  loss 
of  substance,  the  ureter  should  be  treated  as  follows :  If  possible,  the  con- 
tinuity of  the  ureter  should  be  restored  by  the  writer's  method. 

"  23.  If  this  is  not  possible,  the  ureter,  if  injured  in  vaginal  operations, 
should  be  sutured  to  the  base  of  the  bladder  with   a  covering  of  mucous 


OPKKATIUNS   OX    VISCKitA   COXXl-X'TKI)    WITH    I'KKlToX.KLM.     ^79 

meinbrano  as  far  forward  as  ])ossil)le,  with  a  view  to  a  future  implantation 
or  formation  of  vesico- vaginal  tistula  with  colpocleisis. 

"34.  In  injuries  to  the  pelvic  ureter  during  laparotomy,  where  the  con- 
tinuity can  not  be  restored,  and  where  temjiorary  vaginal  implantation  can 
not  be  effected  in  the  female  or  vesical  implantation  in  the  male,  the  proxi- 
mal extremity  of  the  duct  should  be  fastened  to  the  skin  at  the  nearest  point 
to  the  bladder. 

"25.  In  ventral  ureteral  fistulte  opening  near  the  bladder,  the  ureteral 
extremity  may,  in  some  instances,  be  ])lanted  directly  into  the  bladder  with 
out  opening  the  }ieritona3um. 

"  2G.  In  cases  where  the  ureter  will  not  reach  the  bladder,  a  flap  may 
be  raised  from  the  anterior  vesical  wall  and  reflected  upward,  extraperito- 
neally,  to  meet  the  ureter  and  form  a  tubular  diverticulum. 

"  27.  Such  a  flap  may  be  so  elongated  by  a  preliminary  operation  as  to 
transplant  the  peritoneum  back  of  the  fundus,  or  by  accurately  suturing  it 
there  at  a  single  sitting,  that  median  ventral  fistulge  of  the  ureter  may  be 
cured  if  they  open  at  any  point  an  inch  or  more  below  the  umbilicus. 

"  28.  Symphyseotomy  is  a  valuable  and  justifiable  preliminary  step  in 
these  plastic  vesical  operations. 

"  29.  It  is  legitimate  when  both  ends  of  a  cut  ureter  open  upon  the  ab- 
dominal wall  to  try  Eydygier's  method. 

"  30.  Implantation  of  one  or  both  ureters  into  the  rectum  is  absolutely 
unjustifiable  under  all  circumstances,  because :  (1)  The  primary  risk  is  too 
great;  (2)  there  is  great  liability  to  stenosis  of  the  duct  at  the  point  of 
implantation ;  (3)  suppurative  uretero-pyelonephritis  is  almost  absolutely 
certain  to  occur,  either  immediately  or  after  the  lapse  of  months  or  years. 

"  31.  Ligation  of  the  ureter  to  cause  atrophy  of  the  kidney  is  unjustifiable. 

"32.  Extirpation  of  a  normal  kidney  for  injury  or  disease  of  the  ureter 
is  absolutely  unjustifiable,  except  where  the  ureter  can  not  be  restored  in 
one  or  other  of  the  ways  cited." 

Conclusions  of  Fenger  (1894). — "  1.  Accidental  wounds  and  subcutaneous 
ruptures  of  the  ureter  have  not  as  yet  been  objects  of  direct  surgical  pro- 
cedure upon  the  ureter  at  the  seat  of  lesion  (eighteen  cases  since  1848  re- 
covering). It  will  be  advisable,  however,  when  and  as  soon  as  the  diagnosis 
can  be  made,  or  when  lumbar  opening  of  a  peri-ureteral  cavity  containing 
extravasated  urine  is  made,  to  look  for  the  seat  of  rupture,  and,  if  practicable, 
to  restore  the  continuity  of  the  canal. 

"  2.  Catheterization  of  the  ureters  from  the  bladder  for  purposes  of  diag- 
nosis of  diseases  of  the  kidneys  has  given  valuable  information  affecting  the 
decision  for  or  against  operation  on  the  kidney. 

"  3.  In  man,  catheterization  is  practicable  only  through  epicystotomy. 
The  danger  of  this  operation  is  steadily  decreasing. 

"  4.  Catheterization  of  the  ureter  from  the  bladder  as  a  curative  measure 
for  the  evacuation  of  hydro-  or  pyonephrosis  has  occasionally  been  performed 
successfully.  It  is  more  difficult  and  more  uncertain  than  nephrotomy  and 
the  attempt  to  find  and  remedy  the  stenosis  of  the  ureter  from  the  pelvis  of 
the  kidnev. 


880  OPERATIVE   SURGERY. 

"  5.  Dilatation  of  strictures  of  the  ureter  by  elastic  bougies  or  catheters 
has  been  tried  from  the  bladder  by  Kelly  with  temporary  success,  and  from 
the  pelvis  of  the  kidney  by  Alsberg  successfully;  consequently  this  procedure 
is  of  use  in  isolated  cases. 

"  6.  Permanent  catheterization  of  the  nreter  from  the  bladder,  a  fistula, 
or  an  implanted  ureter,  is  often  tolerated  only  for  a  limited  time,  and  must 
be  employed  with  caution  for  fear  of  causing  ureteritis. 

"  7.  Uretero-lithotomy,  longitudinal  incision  over  a  stone  for  its  removal, 
is  a  safe  operation  by  the  extraperitoneal  method.  The  wound  heals  with- 
out stenosis.  In  extraperitoneal  operations  suturing  is  unnecessary,  drain- 
age down  to  the  wound  being  sufficient. 

"  8.  Intraperitoneal  ureterotomy  should  be  done  only  when  access  out- 
side of  the  peritoneal  cavity  is  impossible,  and  it  should  be  completed  by 
careful  suturing,  covering  with  a  peritoneal  or  omental  flap  and  drainage. 

"  9.  Opening  of  the  peritoneal  cavity  to  locate  the  seat  of  the  stone  may 
occasionally  be  necessary,  but,  when  the  diagnosis  is  once  made,  ureterotomy 
for  the  removal  of  the  stone  should  be  done  through  an  extraperitoneal  in- 
cision, and  the  abdomen  closed. 

"  10.  In  valve  formation  or  stricture  of  the  ureter,  causing  pyo-  or 
hydronephrosis  or  a  permanent  renal  fistula,  nejihrotomy  should  be  fol- 
lowed by  exploration  of  the  ureter  in  its  entire  course  from  the  kidney  to 
the  bladder. 

"  11.  Exploration  of  the  ureter  as  to  its  permeability  should  be  done  from 
the  renal  wound  by  a  long,  flexible  silver  probe  (a  uterine  probe)  or  an  elastic 
bougie,  either  olive-pointed  or  not.  If  the  bougie  passes  into  the  bladder  the 
examination  is  at  an  end.  The  size  of  bougie  that  will  pass  through  a  healthy 
ureter  is  from  nine  to  twelve,  French  scale. 

"  13.  If  the  pelvic  orifice  of  the  ureter  can  not  be  found  from  the  renal 
wound  it  should  be  sought  for  by  opening  the  pelvis  (pyelotomy),  or  by 
incising  the  ureter  (ureterotomy). 

"  13.  A  longitudinal  incision,  half  an  inch  to  an  inch  long,  in  the  posterior 
wall  of  tlie  pelvis  can  be  made  while  the  kidney  is  lifted  upward  against  the 
twelfth  rib.  This  procedure  is  easy  if  the  jjelvis  is  dilated,  but  may  be 
impossible  if  the  pelvis  is  of  normal  size. 

"  14.  Operation  for  valve  formation  should  be  done  through  the  wound  in 
the  pelvis.  If  the  opening  can  not  be  seen  or  found  from  the  pelvis  ureterot- 
omy should  be  performed  immediately  below  the  pelvis.  A  small  incision 
should  be  made  in  the  ureter  and  a  probe  passed  up  into  the  pelvis.  The 
valve  should  be  split  longitudinally  and  the  incised  borders  so  treated  as  to 
prevent  reformation  of  the  valve. 

"  15.  A  stricture  in  the  ureter,  if  not  too  extensive,  can  be  treated  by  a 
plastic  operation  on  the  plan  of  the  Heinicke-Mikulicz  operation  for  stenosis 
of  the  pylorus — namely,  longitudinal  division  of  the  stricture  and  transverse 
union  of  the  longitudinal  wound.  This  method  of  operating  for  ureteral 
stricture  seems  to  me  preferable  to  resection  of  the  strictured  part  of  the 
ureter  (Ktister's  operation)  for  the  following  reason  :  It  is  a  more  economical 
operation,  and  preferable  when  the  elongation  of  the  ureter  is  not  sufficient 


Ol'I'lKATloNS   ON    VIS("KKA    CoXN  K(  "I'l':!)   WI'I'll    I'MinToNJOUM.     881 

to  permit  tlie  two  cut  eiuls  of  llu-  ureter  after  excision  (jf  the  stricture,  not 
only  to  come  in  contact,  but  even  to  permit  of  closure  ami  invajfiiuition 
without  stretching. 

"  !(».  Kesection  of  tlie  uj)[)er  end  of  the  ureter  and  im[ihiiitation  of  the 
distal  end  into  the  pelvis  may  be  useful  in  rupture  or  division  or  stricture  of 
tlic  upper  end  of  the  ureter,  as  described  by  Kiistcr, 

"  IT.  In  a  similar  case  of  stricture  in  the  upper  end  of  the  ureter,  espe- 
cially if  the  ureter  were  not  elongated  or  the  kidney  movable,  I  should  i)re- 
fer  the  plastic  operation  proposed  by  me,  as  it  is  easier  of  technique,  and  as 
it  proved  successful  in  my  case  of  traumatic  stricture  in  the  ureter  below  the 
pelvic  orifice. 

"  18.  The  ureter  is  accessible  through  an  extraperitoneal  incision,  from 
the  twelfth  rib  ilown  along  and  one  inch  anterior  to  the  ilium  and  along 
Poupart's  ligament  to  about  its  middle.  This  incision  gives  access  to  the 
U2)per  three  fourths  of  the  ureter  and  down  to  within  two  or  three  inches 
above  the  bladder. 

"  19.  The  vesical  and  lower  pelvic  portions  of  the  ureter  may  be  reached, 
as  Cabot  has  pointed  out,  by  means  of  the  sacral  operation,  or  Kraske's 
method,  modified  by  osteoplastic  temporary  resection  of  the  sacrum.  In 
woman  the  vesical  portion  of  the  ureter  is  accessible  through  the  vagina. 

"  20.  The  vesical  orifice  of  the  ureter  may  be  reached  from  within  the 
bladder  by  suprapubic  cystotomy  in  man,  and  by  dilatation  of  the  urethra, 
or  suprapubic  or  vaginal  cystotomy  in  woman. 

"  21.  Uretero-uterine  fistulge  can  be  treated  satisfactorily  by  plastic 
closure  of  the  vagina  or  by  nephrectomy.  Implantation  of  the  ureter  into 
the  bladder  is,  under  favorable  circumstances,  the  operation  of  the  future 
for  this  condition. 

"22.  Uretero-vaginal  fistulse  and  congenital  urethral  or  vaginal  termina- 
tions of  the  ureter  should  be  treated  by  vaginal  plastic  operation  for  dis- 
placement of  the  proximal  end  of  the  ureter  into  the  bladder.  If  these 
attempts  fail,  and  the  kidney  is  not  infected,  extra-  or  transperitoneal 
implantation  into  the  bladder  should  be  done,  and  finally,  as  a  last  resort, 
nephrectomy. 

"  23.  Complete  transverse  wounds  in  the  continuity  of  the  ureter  should 
be  treated  by  uretero-ureterostomy  after  Van  Hook's  method  of  lateral 
implantation,  if  possible. 

"  2-i.  Complete  transverse  wounds  of  the  upper  end  of  the  ureter  should 
be  treated  by  implantation  of  the  ureter  into  the  pelvis  of  the  kidney,  as 
devised  by  Kiister. 

"  25.  Complete  transverse  wounds  of  the  ureter  near  the  bladder  should 
be  treated  by  implantation  into  that  viscus  either  by  splitting  the  ureter  or 
by  invagination. 

"26.  Loss  of  substance  of  the  ureter  too  extensive  to  permit  of  uretero- 
ureterostomy, or  too  high  up  to  permit  of  implantations  into  the  bladder, 
may  be  treated  by  implantation  on  the  skin  or  into  the  bowel. 

"27.  Implantation  into  the  bowel  is  objectionable  on  account  of  the 
infection  which  is  almost  certain  to  follow  sooner  or  later. 


882 


OPERATIVE  SURGERY. 


"28.  Implantation  into  the  rectum  should  not  be  resorted  to  when 
implantation  into  the  bladder  is  possible. 

"  29.  Implantation  on  the  skin  in  the  lumbar  region,  or  tlie  abdominal 
wall,  may  have  to  be  followed  by  secondary  nephrectomy,  which,  however,  is 
much  less  dangerous  than  the  primary  operation." 


> 


e) 

UKETLRAL  BOUGIES.  | 
DILATING  CATHETERS.  | 


Fui.  lOy.J. — In^itruinents  emjiloyed  in  catlieterisin  of  ureter  in  female. 
a.  Metal  ureteral  sound,  b.  Cystoscope  with  obturator  removed,  c.  Cystoscope  with 
obturator  in  place,  d.  Searcher,  e.  Aiiplicator.  /.  Long  forceps,  g.  Dilator  of 
meatus  and  elastic  ureteral  catheter  witli  stylet.  /;.  Dentists'  wax.  A  good  natural 
or  artificial  light  (Fig.  103)  is  of  great  importance  in  these  examinations.  Patient 
should  be  quiet  when  instrument  is  in  ureter.  An  evaeuator  (Fig.  1088)  is  needed  to 
remove  fluid  from  around  ureteral  openings. 

The  Catheterism  of  the  Ureter.— Catheterism  of  the  ureter  is  now  an 
accepted  fact  of  practical  importance.  The  introduction  of  a  catheter  or 
probe  into  the  ureter  for  the  purpose  of  diagnosticating  the  presence,  nature, 
and  situation  of  morbid  conditions  relating  to  the  kidney  and  ureter,  and 
their  treatment,  is  an  advance  already  assured,  and  soon  bids  fair  to  become 
a  general  established  means  of  investigation  and  treatment.  For  anatomical 
reasons,  the  female  patient  has  thus  far  reaped  the  greatest  benefit  from 
this  advance. 


()Im:i;ai'1().\s  ox  nisckka  coNNEcriii)  with  periton.I'^um.    883 


The  lrchni(iHv  of  cit/Zic/crism  of  the  iii'ctcr  is  (|uite  coiii))lic:it(!(l  ;uul  dilli- 
<'ult,  of  iitiliziitioii  except  by  those  !iiii[)ly  lillcil  by  i'.\[)t!rience;iii(l  instrumental 
e(iuiitnioiit  for  the  j)urpose. 

T/tc  (ui  of  nit/ie/eris/n,  as  \)Viic{ice{\  by  Kelly,  is  elTected  in  bi'ief  ms  fol- 
lows :  Cause  the  putieiit  to  empty  the  bUuldcr  while  in  tiie  erect  or  sitting 
posture  ;  phice  the  patient  on  the  table  in  knee-breast  (Fig.  108G)  or  elevated- 
ilorsal  position  (Fig.  108T) ;  cause  an  assistant  to  separate  and  retain  apart 
the  buttocks  and  labia;  cleanse  the  urethral  orifice  carefully  with  boric-acid 
solution;  dilate  the  urethra  cautiously;  smear  the  end  of  the  speculum 
with  a  sterilized  oleaginous  substance  and  apply  the  end  of  the  instrument 
to  the  urethral  opening  and  i)ush  it  into  the  bladder  with  a  gentle  sweep 
beneath  the  pubic  arch  ;  withdraw  the  obturator  with  a  slight  rotary  motion, 
noting  the  entrance  of  air  and  distention  of  the  bladder  on  the  withdrawal ; 
adjust  the  head  mirror  and  direct  an  assistant  to  hold  the  electric  light  so 
as  to  cause  the  reflected  rays  to  fall  Avithin  the  bladder;  inspect  carefully 
the  accessible  walls  of  the  organ  by  turning  slowly  the  speculum  in  various 
directions;  depress  decidedly  the  instrument  (kuee-breast  posture)  to  bring 


Fig.  1086. — The  knee-breast  position. 

the  vesical  triangle  into  view,  noting  that  this  area  is  more  deej^ly  injected 
than  are  the  mucous  membranes  elsewhere  in  the  bladder ;  turn  the  specu- 
lum to  the  right  or  left  about  fifteen  to  twenty  degrees,  and  observe  the  pink 
eminence  denoting  the  position  of  the  ureteral  orifice;  watch  it  for  a  brief 


884 


OPERATIVE  SURGERY. 


time  (thirty  seconds)  to  observe  the  ejection  of  urine ;  wipe  the  ureteral 
opening  with  aseptic  cotton  if  tlie  bladder  or  kidney  be  diseased  ;  grasp  the 
catheter,  steadied  Avith  a  stylet,  and  lubricate  the  extremity ;  introduce  the 
extremity  into  the  ureter  and  carefully  })usli  it  up  a  little  way  ;  partially  with- 
draw the  stylet  as  the  catheter  is  made  to  advance;  push  the  latter  upwai-d 
into  the  pelvis  of  the  kidney  if  desired;  withdraw  the  speculum  and  retain 
the  patient  in  position  if  the  catheter  is  soon  to  be  removed,  if  not,  place  her 
u})on  the  side,  carefully  retaining  the  catheter  in  place  during  the  change  of 
posture.  If  the  object  of  the  introduction  is  to  flush  the  pelvis  of  the  kid- 
ney, the  catheter  should  be  small  enough  to 
permit  a  refluence  along  the  outer  surface 
of  the  instrument  into  the  bladder,  from 
which  it  may  be  caused  to  escape  through 
a  second  catheter  introduced  through    the 

r/   ' 


Fig.  1087. — The  elevated  dorsal  position. 

urethra  by  the  side  of  the  first.  If  the  fluid  introduced  into  the  kidney  be 
colored  its  escape  from  the  bladder  will  then  be  convincing  of  the  complete- 
ness of  the  circuit.  If  the  condition  of  the  kidney  is  to  be  determined  by 
the  characteristics  of  the  urine,  a  metal  catheter  should  be  employed  with  a 
rubber-tube  attachment  to  the  outer  end  by  means  of  which  the  urine  can 
be  collected.  If  at  this  time  the  bladder  be  thoroughly  cleansed  and  com- 
pletely emptied,  the  urine  withdrawn  from  it  thereafter  will  iiulicate  the 
condition  of  the  opposite  kidney.  The  catheterization  of  both  kidneys  will 
enable  one  to  determine  the  condition  of  either  by  the  characteristics  of  the 
respective  urines.     If  the  ureter  or  kidney  is  to  be  sounded  for  stone  a  metal 


OI'IIKATIOXS   OX    NISCKKA    COXNKCTKI*    Willi    IMlKIToX J-U'M.     yy5 

instrimient  iiiiiy  be  employed  (Fig.  1<)85,  a),  or  one  tipixul  with  wiix,  or  witli  an 
extremity  readily  roughened  by  friction.  Cases  in  wliich — because  of  weak- 
ness, great  weight,  or  other  cogent  reasons — the  re-strained  postures  already 
described  are  not  suitable  for  catheterisin,  Kelli/  introduces  the  catheter  with 
the  patient  lying  on  the  back  and  the  thighs  drawn  upward.  The  bladder  is 
emptied,  the  cystoscope  introduced,  the  outer  end  strongly  elevated,  the  inner 
turned  to  the  right  or  left  side  of  the  base  of  the  bladder,  and  the  nuu-ous 
mi'inbraue  at  the  end  of  tlu;  si)e('iilu!n  is  cxaniiiied  for  the  o])ening.  If  it  be 
not  fouiul  at  lirst  tlie  instrument  is  witlulrawn  to  the  neck  of  the  bladder  to 
determine  its  exact  position.  It  is  then  pushed  inward  to  one  side,  hoping  to 
bring  the  oritice  within  the  field.  Sometimes  it  can  be  promptly  accomplished 
in  this  way;  again,  it  may  be  necessary  to  pass  the  end  of  the  instrument 
lightly  across  the  mucous  membrane,  and  not  infrequently  the  use  of  the 
searcher  (d)  is  needed  to  detect  the  opening.  One  not  thoroughly  familiar 
with  the  practice  need  hardly  expect  to  succeed  under  these  circumstances. 

The  Precautions. — In  catheterism  of  the  ureter  thorough  asepsis  should 
be  ])racticed  in  all  respects  to  prevent  infection  of  the  kidney.  The  urethra 
should  be  stretched  carefully,  so  as  not  to  cause  needless  dilatation  and  loss 
of  power.  The  speculum  should  be  introduced  with  relation  to  the  curve 
of  the  arch  of  the  i)ubis  to  avoid  injury  of  the  urethra.  Careful  introduc- 
tion of  instruments  into  the  ureter  and  kidney  is  urged  to  prevent  perfora- 
tion of  the  former,  and  puncture  of  the  latter,  structure. 

The  Remarks. — If  fluid  obscures  the  ureteral  orifice,  withdraw  it  by 
means  of  the  evacuator  (Fig.  1088).  A  catheter  nuiy  be  kept  in  the  ureter 
for  several  hours,  and  even  for  three  or  four  days  in  some  cases.  Flexible 
instruments  are  the  safer  for  use.  Catheters  employed  in  the  kidney  should 
be  longer  than  those  limited  to  the  ureter.  Wire  stylets  may  be  inserted  or 
not  in  either  case,  depending  on  the  stilfness  of  the  catheters  and  the  need 
for  increased  iiressure  in  the  introduction.     Metal  catheters  are  used  when 


Fig.  loss;.— The  evacuator. 


the  canal  is  constricted  or  tortuous.     ^letal  and  hard-rubber  bougies  for  dila- 
tation are  serviceable  in  those  cases.     If  a  bougie  (with  the  tip  covered  with 


886  OPERATIVE   SURGERY, 

dentists'  wax,  Fig.  1085,  h)  be  pressed  against  a  stone  in  the  nreter  or  kidney 
the  wax  will  bear  evidence  of  the  nature  of  the  contact.  The  knee-breast 
posture  is  better  than  the  elevated  dorsal  for  stout  patients. 

Kelly  nses  boro^lyceride  solution  to  lubricate  the  instruments.  An 
electric  headlight  (Fig.  103)  is  economic  and  advantageous  in  many  instances. 
It  frequently  liap})ens  that  the  most  cautious  use  of  these  instruments  is  fol- 
lowed by  bleeding  from  the  ureter.  In  very  nervous  patients,  and  at  a  tirst 
examination,  general  anesthesia  may  be  required.  A  four-per-cent  cocain 
solution  will  deaden  the  sensibility  of  the  urethra  and  bladder  sufticiently 
for  the  purposes  of  the  steps  of  the  procedure. 

Catheterism  of  the  ureters  in  the  female  is  quite  easily  accomplished  by 
means  of  the  ureter  cystoscopes  of  Brenner,  Casper,  Xitze  (page  ),  and 
others.  But  familiarity  with  their  use  is  quite  as  essential  to  success  as 
with  the  method  of  Kelly  just  described. 

BrotoJi  has  lately  planned  an  instrument  with  a  double-,  instead  of  a  sin- 
gle-barreled catheter  attachment,  by  means  of  which  modification  he  hopes 
to  be  able,  in  favorable  cases,  to  catheterize  both  ureters  at  about  the  same 
time,  and  at  least  to  introduce  one  or  the  other  of  the  catheters,  utilizing  the 
remaining  channel  or  barrel  in  regulating  the  amount  and  character  of  the 
fluid  in  the  bladder,  thus  contributing  at  once  to  the  success  of  the  under- 
taking. Also  he  hopes  to  be  able  to  siphon  from  the  bladder  with  the  dis- 
engaged catheter  the  fluid  coming  from  the  free  ureter,  and  even,  after  rais- 
ing the  "intervening  vesical  ridge"  from  within  the  vagina  or  rectum,  to 
separately  siphon  the  fluids  coming  from  the  respective  openings. 

Brown  reported  *  55  instances  of  ureter  catheterism  without  general 
anesthesia,  of  which  28  were  males  and  27  females.  In  the  great  majority 
of  tliese  cases  the  Brenner  instrument  was  employed. 

Cocain  anesthesia  contributes  to  the  comfort  of  the  patient,  and  corre- 
spondingly facilitates  the  conduct  of  the  procedure.  The  presence  in  the 
bladder  of  a  small  amount  of  fluid  is  essential  for  the  purpose. 

In  cases  in  which  for  any  reason  ureter  catheterism  is  not  available,  a 
difEerentiation  of  the  fluids  may  be  sought  by  other  means.  The  closure  of 
one  ureter  by  pressure  variously  applied,  and  of  a  ureter  opening  by  similar 
means,  the  employment  of  suction  at  the  vesical  orifices  (Fenwick),  and  the 
separation  and  collection  of  the  fluids  by  special  apparatus  (Harris),  are  all 
ingenious,  and  each  is  effective  in  conformity  with  the  period  of  its  incep- 
tion. 

Harris's  Method. — The  method  of  Harris  enables  one  to  examine  sepa- 
rately the  unmixed  urine  of  each  kidney.  Harris  thus  describes  the  instru- 
ment (Fig.  1089)  devised  by  himself  for  the  purpose:  "  It  consists  of  a  double 
catheter  {a,  a),  each  being  separate  throughout,  but  both  being  inclosed  in  a 
common  sheath  (b)  throughout  its  shaft  or  straight  portion,  thus  giving  it 
the  appearance  of  a  single  flattened  tube.  Each  catheter  is  separately 
movable  about  its  longitudinal  axis  within  the  sheath.  On  the  flattened 
surfaces  and  the  lateral  portions  of  the  semicircular  surfaces  are  a  number 

*  Annals  of  Surgery,  December.  1809. 


oi'Ki;a'I'I(>.ns  ox  visckka  ('onnkcti:!*  wiiii   i*i;i.m  loxja  .m.    ^^7 

of  small  iRTroraLiuus.  'I'lic  disLal  f.\Lrumit.y  oi'  cat-li  caLliclcr  is  round  and 
cui'Vfd  in  the  same  plane  as  the  proximal  extremity,  forming  about  a  quad- 
rant of  a  circle,  the  same  as  the  curved  end  of  an  ordinary  nude  souml. 
The  curves  of  the  two  extremities  bein_<;  on  the  same  plane,  the  distal  end 
will  always  iiulicate  accuiatcly  the  exact  direction  of  the  |)r(»xiiiial  end.  The 
distal  extremity  of  each  catheter  is  connected  by  means  of  a  short  piece  of 
rubber  tubini^  (r,  c)  with  a  separate  glass  vial.  Tiie  corks  of  the  vials  are 
doubly  perforated  and  each  vial  is  finally  connected  by  a  piece  of  rubber 
tubing  with  a  single  rubber  exhaust  bulb(r/).     There  is  a  metal   lever  ((») 


Fig.  1089. — The  differentiation  of  urines,  Harris's  instrument,  a,  a.  Double  catheter,  h. 
Common  sheath,  c,  c.  Rubber  tubing  connecting  catheters  with  vials,  d.  Exhaust 
bulb.     e.  Metal  lever,     f.  Fork  connecting  with  the  lever. 


about  eleven  and  a  half  inches  long,  with  a  handle  at  one  end,  the  extremity 
being  suitably  curved  and  flattened,  laterally.  This  lever  is  provided  with  a 
single  perforation  near  the  handle,  is  flattened  at  the  sides,  and  notched 
along  its  lower  border.  A  detachable  curved  forked  metal  piece  connects 
the  catheter  with  the  lever  when  in  use  (/).  This  connecting  piece  is 
provided  with  a  spiral  spring  arranged  to  catch  in  the  iiotches  on  the  under 
surface  of  the  lever.  The  instrument  is  used  in  the  following  manner  :  The 
patient,  male  or  female,  is  placed  comfortably  on  a  table  in  the  ordinary 
lithotomy  position,  the  hips  being  as  high  as  the  shoulders.  The  instrument 
with  the  flattened  surfaces  in  contact,  so  as  to  form  practically  a  single 
catheter,  is  introduced  into  the  bladder  in  the  ordinary  manner.  The  con- 
necting piece  (/)  is  attached.  The  lever  {e)  passing  through  the  forked  con- 
necting piece  is  now  introduced  into  the  vagina  in  the  female,  or  the  rectum 
in  the  male.  The  fork  holds  it  in  the  midline.  When  introduced  the  proper 
distance,  as  indicated  by  the  perforation  in  the  lever  coming  opposite  the 
perforations  in  the  forked  piece,  it  is  fastened  by  passing  the  pin  in  the 
forked  piece  through  the  perforation  in  the  lever.  The  instrument  in  the 
bladder  is  now-  opened  by  slowly  and  gently  rotating  each  catheter  about  its 
longitudinal  axis  tintil  each  proximal  end,  as  indicated  by  the  distal,  is 
directed  outward  and  backward.  The  angle  subtended  posteriorly  by  the 
ends  of  the  catheters  should  be  about  100°  to  110°.     They  are  held  in  this 


888  OPERATIVE  SURGERY. 

position  by  the  small  spiral  spring.  In  opening  this  way,  the  end  of  the 
lever  within  the  vagina  or  rectum  passes  up  between  the  ends  of  the  cathe- 
ters, so  as  to  form  a  septum  extending  longitudinally  along  the  base  of  the 
bladder.  The  end  of  the  lever  is  held  snugly  in  between  the  diverging  ends 
of  the  catheters  by  the  spiral  spring  catching  in  the  notches  on  the  under 
surface  of  the  lever.  It  will  be  seen  now  that  the  end  of  each  catheter  in 
the  bladder  occupies  the  bottom  of  a  jDocket,  the  pockets  being  separated  by 
a  perfect  septum  or  watershed.  The  ureters  open,  one  on  either  side  of  the 
watershed,  near  the  base  of  the  declivity  in  the  immediate  vicinity  of  the 
respective  ends  of  the  catheters.  By  producing  a  very  slight  exhaustion  of 
the  air  in  the  vials  by  means  of  the  bulb,  the  urine,  as  fast  as  it  escapes  from 
the  ureters,  drops  directly  into  the  ends  of  the  catheters  and  flows  at  once 
into  the  vials,  right  and  left  respectively.  Before  attaching  the  vials  to  the 
catheters,  the  little  pockets  in  the  bladder  may  be  thoroughly  irrigated  and 
cleansed,  if  thought  desirable,  by  connecting  an  irrigator  with  the  short, 
straight  tip  on  the  catheters,  closing  the  other  opening  with  the  finger,  thus 
washing  through  one  catheter  and  out  of  the  other."  Cases  are  sometimes 
met  with  in  which  urinary  differentiation  can  not  be  practiced. 

It  is  proper  to  state  at  this  time  that  the  use  of  this  instrument  may  be 
badly  borne  by  the  patient  and  be  followed  by  annoying  vesical  irritation. 
If  badly  adjusted  it  may  close  a  ureter. 

Doiunes  suggests  a  simpler  apparatus  for  the  purpose,  for  which  he 
claims  all  of  the  merits  and  fewer  of  the  discomforts  that  belong  to  the 
Harris  apparatus. 

OPERATIOXS    OX    THE    SPLEEN". 

The  operations  performed  on  the  spleen  are  splenectomy,  splenopexy, 
aspiration,  and  splenotomy. 

The  Anatomical  Points. — The  spleen  lies  between  the  fundus  of  the  stom- 
ach and  the  diaphragm.  The  lower  end  reaches  to  the  first  lumbar  spine ; 
the  upper  to  the  ninth  dorsal  spine ;  the  external  surface  corresponds  to  the 
ninth,  tenth,  and  eleventh  ribs.  The  inner  end  is  distant  about  an  inch  and 
a  half  from  the  median  plane  of  the  body,  and  its  outer  end  about  reaches 
the  midaxillary  line  (Quain).  The  long  axis  corresponds  to  the  tenth  rib. 
The  peritonaeum  is  reflected  at  the  hilum,  incloses  the  splenic  vessels,  and 
together  they  constitute  the  j^edicle  of  the  viscus,  in  a  surgical  sense.  The 
suspensory  ligament  of  the  spleen  is  a  double  fold  of  peritonaeum  connecting 
the  organ  with  the  under  surface  of  the  diaphragm ;  the  left  crus  of  the 
diaphragm,  the  suprarenal  capsule,  and  the  flexure  of  the  colon  lie  behind 
it.  The  splenic  artery  is  large,  tortuous,  and  gives  off  numerous  branches 
near  the  hilum,  some  of  which,  the  vasa  brevia,  pass  backward  to  the  stom- 
ach. These  branches  should  be  avoided  in  the  ligature  of  the  pedicle,  if 
possible.  The  splenic  vein  is  large  and  lies  below  the  artery.  These  vessels 
are  surrounded  by  a  minimum  amount  of  connective  tissue,  hence  they  are 
quite  easily  isolated  and  ligatured  singly. 

Splenectomy. — After  thorough  aseptic  preparation  of  the  patient,  make 
an  incision  throucrh  the  outer  edge  of  the  left  rectus  muscle  down  to  the 


ol'KUA'I'loNS   ON    VISCHliA   ("oXNKCTKI)    WII'll    I'KIMToN JILM.     yy*) 

peritoiiit'iiin  ;  ])iish  jiside  tlie  intcstiiies,  expose  the  spleen  and  isolate  it  with 
broad  Hat  sponges  or  wipers;  ligature  and  divide  the  adliesions,  also  the 
gastro-sj)leiue,  tlie  lieno-renal,  and  jjhreiiico-splenic  ligaments,  carefully 
avoiding  traction  upon  the  latter;  depress  the  parietes  to  lessen  traction  on 
the  pedicle  ;  commencing  at  the  lower  extremity,  carefully  expose  and  deliver 
the  viscus ;  cautiously  locate  and  secure  the  ])edicle,  either  en  masse  or  by 
separate  ligature  of  the  vessels ;  divide  the  pedicle  with  scissors  or  cautery, 
tying  independently,  perhaps,  the  open  ends  of  the  vessels  for  better  security ; 
remove  the  organ  and  drop  the  pedicle  into  the  abdomen  or  attach  it  to  the 
abdominal  wound  if  secondary  h;eniorrhage  be  feared;  wij)e  out  the  field 
of  operation,  carefully  avoiding  the  pedicle ;  arrest  the  oozing,  close  the 
abdominal  wound  in  the  usual  manner,  unless  otherwise  indicated. 

71ie  Precautions. — As  Greig  Smith  wisely  said,  "  The  success  or  failure 
of  the  operation  may  be  truthfully  said  to  depend  on  the  treatment  of  the 
pedicle."  A  fatal  outcome  has  often  occurred  in  a  few  hours  in  the  practice 
of  the  most  skilled  surgeons.  It  is  difficult  to  lay  down  a  hard-and-fast  rule 
for  treatment  of  the  pedicle,  since  it  so  often  varies  in  size,  length,  relation 
of  the  branches  to  the  main  trunk,  etc.  Tliornton  succeeded  with  two  locked 
ligatures,  supplemented  by  a  single  one  surrounding  the  entire  pedicle.  The 
separate  ligature  of  the  important  vessels  is  a  reliable  method,  if  the  length 
of  the  pedicle  and  the  relation  of  their  branches  to  the  proposed  seat  of  lig- 
ature will  permit.  Double  ligaturing  should  be  practiced  and  the  vessels 
divided  between  them  when  possible.  The  free  use  of  clamps  before  ligatur- 
ing, and  after,  in  advance  of  division  of  the  pedicle,  is  a  wise  measure. 
Greig  Smith  advises  the  employment  of  pressure  forceps  in  successive  pairs, 
the  division  of  the  vessels  between  them,  and  ligature  as  the  forceps  are  re- 
moved in  turn.  The  vessels  of  the  pedicle  should  invariably  be  tied  while  in 
a  relaxed  condition.  Tension  of  the  pedicle  or  twisting  may  prove  fatal 
by  causing  shock  or  rupture  of  the  vessels.  Needlessly  tight  ligaturing  is 
dangerous,  because  of  the  liability  of  the  ligature  to  cut  its  way  out. 

Jonnesco  and  many  other  experienced  surgeons  regard  with  favor  the 
incision  at  the  linea  alba  (Fig.  903),  supplemented  if  need  be  by  a  transverse 
one  so  located  as  to  afford  the  most  room  and  best  opportunity  for  observa- 
tion. The  adhesions  and  serous  ligaments  should  be  divided  between  two 
ligatures  to  avoid  the  perplexities  of  oozing,  and  possibly  a  severer  flow. 
Rough  and  careless  efforts  at  separation  of  adhesions  of  the  organ  to  con- 
tiguous structures  may  cause  profuse  bleeding  from  rupture  of  the  capsule, 
requiring  the  use  of  the  actual  cautery,  ligating  en  masse,  etc.,  for  arrest. 
Delivery  of  the  organ  from  the  abdominal  wound  should  be  made  to  the  left 
or  from  below  upward.  The  former  best  exposes  to  treatment  the  pedicle, 
which  in  either  instance  should  not  be  made  tense,  and  especially  when  the 
phrenico-splenic  ligament  is  unsevered,  as  traction  on  this  ligament  appears 
to  cause  profound  shock,  possibly  by  interference  with  the  respiratory  func- 
tion. A  bleeding  point  is  frequently  noted  on  the  left  crus  of  the  dia- 
phragm. 

The  Remarks. — If  the  adhesions  of  the  spleen  are  dense  and  extensive, 
removal  of  the  organ  should  not  be  attempted.     The  posterior  surface  of  the 


890  OPERATm:  SURGERY. 

pedicle  may  have  become  adherent  to  the  tail  of  the  pancreas,  requiring  care 
in  separation,  and  possibly  removal  of  part  of  the  pancreas  itself.  Every 
preparatory  precaution  should  be  taken  to  anticipate  and  successfully  treat 
the  occurrence  of  shock.  The  dangers  from  secondary  haemorrhage  require 
a  careful  arrest  of  all  bleeding  before  the  wound  is  closed. 

Partial  resections  of  the  spleen  are  sometimes  made  for  the  purpose  of 
removal  of  innocent  tumors  and  limited  lacerations  with  the  view  of  avoid- 
ing the  sequels  that  follow  complete  removal.  The  part  of  the  organ  to  be 
removed  is  exposed  and  the  portion  of  the  gastro-splenic  ligament  corre- 
sponding to  it  is  tied  in  sections  between  two  ligatures  and  divided.  The 
same  part  is  then  circumscribed  with  a  continuous  ligature  of  strong  silk 
passed  through  in  the  following  manner  (Jordan) :  Arm  a  long  needle  with 
the  ligature  ;  pass  the  needle  through  the  spleen  from  the  under  surface  half 
an  inch  from  the  border,  and  draw  the  ligature  upward  until  half  its  length 
appears  above ;  carry  the  lower  half  upward  around  the  lower  border  of  the 
organ  and  tie  tirmly  with  the  upper  half  at  the  seat  of  the  needle  puncture ; 
pass  the  needle  through  the  spleen  within  an  eighth  of  an  inch  of  the 
outer  side  of  the  turn  close  to  the  ligature ;  repass  the  needle  from  the 
under  surface  upward  through  the  organ  half  an  inch  farther  along  and  tie 
as  before  the  included  portion  ;  repeat  these  steps  until  the  line  of  proposed 
occlusion  is  traversed,  finally  tying  the  ends  over  the  border  of  the  spleen  in 
a  reef  knot;  excise  the  tied-off  portion,  cauterize  any  oozing  points  that  may 
appear,  cleanse  the  wound,  and  close  the  abdominal  wound.  This  jilan  is 
certainlv  more  secure  than  that  of  transfixion  pins  and  elastic  ligatures  com- 
bined with  cautery. 

The  Results. — In  28  cases  of  splenectomy  for  leucaemia,  25  died  from  the 
immediate  effects  of  the  operation,  20  of  which  occurred  in  the  first  12  hours 
from  hemorrhage.  Twelve  deaths  followed  29  operations  for  hypertrophy 
due  to  malaria  ;  in  43  cases  done  for  simple  hypertrophy  and  wandering 
spleen,  the  death  rate  was  20  per  cent;  18  to  40  per  cent  when  practiced  for 
cysts,  and  25  to  30  per  cent  for  malignant  disease.  The  removal  of  large 
tumors  is  especially  fatal.    Later  estimates  make  the  rate  less  than  15  per  cent. 

Splenopexy. — Splenopexy  is  the  fixation  of  the  spleen  to  some  part  of 
the  abdominal  wall.  It  is  sometimes  j^i'^cticed  to  secure  relief  and  avoid  at 
the  same  time  the  high  rate  of  mortality  that  attends  the  removal  of  the 
organ.  Bi/dygier  introduced  the  operation,  and  reported  a  successful  case 
in  1895.  He  entered  the  abdomen  at  the  median  line  by  a  vertical  incision, 
raised  the  spleen  upward  to  a  proper  point  for  fixation,  and  detached  suffi- 
cient parietal  peritonaeum  to  form  a  retentive  pocket.  The  peritona?ura  was 
divided  transversely  with  an  upward  convexity  and  detached  from  above 
downward  to  a  sufficient  dimension  to  provide  a  pocket  for  the  reception  of 
the  lower  half  of  the  spleen.  To  prevent  further  detachment  of  the  peri- 
tonaeum, it  was  sewed  to  the  underlying  structures  around  the  limits  of  its 
separation.  The  spleen  was  placed  in  the  pocket,  the  border  of  which  was 
sutured  to  the  gastro-splenic  omentum  which  lay  above  it. 

Bardenhauer  placed  the  spleen  practically  outside  the  peritoneal  cavity 
in  the  following  manner :  He  made  a  vertical  incision  between  the  ribs  and 


ol'KKA'rio.NS   ON    VlSCllUA   CUNxVKCTED    WITH    ri:iilT(J\j:L\M.     Sdl 

iliac  crest,  and  joined  to  it  a  transverse  one  carried  along  the  lower  border  of 
tenth  rib.  He  detached  the  flap  thus  outlined  down  to  the  peritona-uni  and 
held  it  aside  wiiile  an  opening  was  made  through  the  latter  large  enough  to 
admit  the  spleen  by  its  smallest  diameter.  The  sjjleen  was  then  drawn 
through  the  peritoneal  opening,  the  border  of  which  was  drawn  closely 
around  the  pedicle  by  means  of  a  purse-string  suture.  A  strong  suture  of 
silk  was  then  passed  under  the  spleen's  end  and  above  over  the  tenth  rib,  so  as 
to  form  a  retentive  sling  for  the  spleen.  Additional  strengthening  sutures 
were  applied  at  suitable  sites  and  the  ilap  was  replaced  and  sutured. 

Zi/koic  has  conceived  the  idea,  based  on  animal  experimentation,  of 
establishing  tixation  by  means  of  a  network  of  catgut  carried  round  the 
organ  and  fastened  by  its  ends  to  the  abdominal  wall,  the  idea  being  that  the 
cicatricial  tissue  that  replaces  the  catgut  will  hold  the  organ  in  position. 
Contraction  of  the  spleen  seems  to  have  followed  this  practice  in  animals. 

Hie  Jiesiilts. — This  operation  is  a  safer  procedure  than  splenectomy,  but, 
unfortunately,  is  not  always  permanent. 

Aspiration  of  the  spleen  and  splenotomy  are  rarely  done.  The  former  is 
a  hazardous  })rocedure  and  should  not  be  practiced.  The  danger  from 
sepsis  and  ha?morrhage  is  comparatively  great,  in  view  of  the  apparent  sim- 
plicity of  the  act.  Tlie  death  rate  from  aspiration  of  cysts  only  is  from  18 
to  49  per  cent. 

Splenotomy  consists  in  opening  into  the  spleen  below  the  ribs  to  reach  a 
cyst  or  abscess  for  evacuation  and  treatment  by  the  open  method.  The  danger 
of  peritoneal  infection  in  septic  cases  in  the  absence  of  adhesions  is  evident. 
Therefore,  adhesion  should  be  secured  if  possible ;  if  not,  careful  packing 
■with  gauze  should  precede  the  incision  of  the  spleen.  After  exposure  of  the 
spleen,  aspiration  should  precede  incision,  which  latter  is  freely  made,  and 
the  cavity  drained  with  gauze.  If  necessary  the  entrance  can,  with  proper 
precautions,  be  made  between  the  ribs. 

OPERATIOXS  ox  THE  PANCREAS. 

The  great  depth  of  the  pancreas,  and  its  intimate  and  important  environ- 
ments, have  made  extended  operations  on  the  viscus  dangerous  and  of  some- 
what doubtful  utility.  Improved  technique  and  a  better  understanding  of 
the  nature  of  its  morbid  processes  have  lessened  the  dangers,  but  not  suffi- 
ciently to  disarm  in  the  least  the  greatest  caution  in  operative  procedures. 

The  Anatomical  Points. — The  pancreas  lies  deeply  in  the  abdomen,  the 
anterior  surface  is  in  contact  with  the  stomach,  and  the  central  part  of  the 
inferior  surface  is  covered  with  the  lower  layer  of  the  transverse  mesocolon. 
The  posterior  surface  is  separated  from  the  spine  by  the  aorta,  vena  cava, 
superior  mesenteric  vessels,  and  crura  of  the  diaphragm.  The  head  of  the 
organ  is  embraced  by  the  duodenum  and  the  tail  lies  in  contact  with  the 
spleen.  It  is  in  relation  with  the  portal  vein  behind,  toward  the  right 
extremity.  At  the  upper  border  and  at  the  posterior  surface  lie  the  splenic 
artery  and  vein.  The  common  bile  duct  lies  closely  behind  the  head  of  the 
pancreas  and  is  sometimes  imbedded  in  its  structure.  The  blood  supply  of 
the  organ  comes  from  the  splenic,  pancreatico-duodenal,  and  the  superior 


892  OPERATIVE   SURGERY. 

mesenteric  arteries.  But  little  of  established  practical  importance  is  yet 
determined  in  the  surgery  of  the  pancreas,  except  the  operation  for 
cysts. 

The  Operatiun  for  Fancreatic  Cyst. — Make  a  short,  straight,  vertical 
incision  in  the  median  line  down  upon  the  tumor  and  arrest  hgemorrhage. 
If  adhesions  he  present,  respect  them,  and  remove  much  of  the  contents  of 
the  cyst  with  an  aspirating  trocar ;  incise  the  cyst,  evacuate  the  remaining 
contents,  stitch  the  edges  of  the  incision  to  the  borders  of  the  abdominal 
wound,  and  introduce  a  drainage  tube.  If  adhesions  he  not  jjresent,  care- 
fully incise  and  draw  aside  the  overlying  omentum  and  ligature  the  bleeding 
points ;  introduce  the  aspirating  trocar  and  remove  enough  of  the  fluid  to 
relax  the  walls  of  the  cyst,  which  are  then  seized  with  catch  forceps  and 
drawn  well  forward  into  the  abdominal  wound  ;  turn  the  patient  to  one  side 
and  incise  the  cyst  wall  sufficiently  to  admit  a  large  drainage  tube,  after 
which  the  borders  of  the  cyst  are  sewed  to  the  abdominal  incision. 

The  amount  of  fluid  subsequently  discharged  is  often  great,  requiring  care- 
ful oiling  of  the  surface  and  also  frequent  changing  of  the  dressings  to  prevent 
irritation.  The  tube  is  shortened  from  time  to  time,  and  the  size  lessened  as 
shrinkage  of  the  sac  takes  place. 

The  Remarks. — The  abdominal  incision  is  sometimes  made  over  the  most 
prominent  point  of  the  tumor,  in  the  belief  that  it  will  correspond  more 
nearly  to  the  seat  of  the  exciting  cause.  Leith  advises  a  posterior  incision  at 
the  left  side,  under  the  twelfth  rib,  through  which  the  fingers  along  the 
outer  border  of  the  quadratus  lumborum  seek  the  kidney  and  tail  of  the 
pancreas.  Here  the  lesser  peritoneal  cavity  can  be  entered  through  the 
mesocolon  or  peritonaeum.  Exploratory  puncture  can  be  practiced  for  diag- 
nostic purposes,  but  with  the  danger  of  leakage  and  peritonitis,  and  also  of 
injury  of  contiguous  structures.  The  aspiration  treatment  is  not  only  dan- 
gerous but  ineffective,  as  the  fluid  rapidly  reaccumulates.  Extirpation  of  the 
cyst  ought  not  to  be  attempted  except  for  some  weighty  reason,  but  unhealthy 
isolated  parts  of  the  cyst  wall  should  be  removed  when  practicable,  pro- 
vided their  loss  does  not  require  that  undue  traction  be  made  to  join  the 
borders  to  the  abdominal  opening.  If  there  be  good  reason  for  the  act,  pre- 
liminary incision  with  gauze  packing  can  be  practiced  to  insure  serous  union 
before  evacuation  of  the  contents. 

Tlie  Results. — In  incision  and  drainage  the  results  of  the  operation  are 
exceedingly  favorable — i.  e.,  65  cases  with  7  deaths.  Cases  with  a  pedicle 
are  often  extirpated  unless  pancreatic  tissue  be  spread  upon  the  surface;  113 
have  been  thus  treated,  of  which  11  recovered. 

Further  indications  for  operation  are  given  by  Senu,  to  whom  the  pro- 
fession is  largely  indebted  for  the  development  of  surgery  of  the  pancreas. 

"  Partial  excision  of  the  splenic  portion  of  the  pancreas  is  indicated  in 
cases  of  circumscribed  abscess  and  malignant  tumors,  and  in  all  cases  where 
the  pathological  product  can  be  removed  completely  without  danger  of  com- 
promising pancreatic  digestion  or  inflicting  abdominal  injury  upon  impor- 
tant adjacent  organs. 

"  Ligation  of  the  pancreas  at  a  point  or  points  of  section  should  precede 


(•i'i:i:Ari(»Ns  on  visckra  {"(>nxi:("I"i:i)  wii'ii   i^huitoxjoi'm.    ,su3 

extirpation  as  a  prophylactic  measure  a<,Minst  troublesome  hiemorrliage  and 
extravasation  of  pancreatic  juice  into  the  {)eritoneal  cavity. 

"  The  formation  of  an  external  pancreatic  fistnla  by  abdominal  section 
is  indicated  in  the  treatment  of  cysts,  abscesses,  gangrene,  and  hnTnorrhage 
of  the  pancreas  dne  to  local  canses. 

"Abdominal  section  and  lumbar  drainage  are  indicated  in  cases  of  ab- 
scess or  gangrene  of  tiie  pancreas  where  it  is  found  impossible  to  establisii 
an  anterior  abdominal  fistula. 

''  Thorough  ilrainage  is  indicated  in  cases  of  abscess  and  gangrene  of  the 
pancreas  with  dilTuse  burrowing  of  pus  in  the  retro])eritoneal  space. 

"  Removal  of  an  impacted  pancreatic  calculus  in  the  duodenal  extremity 
of  the  duct  of  Wirsung,  by  taxis,  or  excision  and  extraction,  should  be  j)rac- 
ticed  in  all  cases  where  the  common  bile  duct  is  compressed  or  obstructed 
by  the  calculus  and  death  is  threatened  by  cholffiinia." 

It  is  proper  to  say  that  much  time  and  greater  experience  will  be  needed 
to  demonstrate  the  utility  of  many  of  these  indications. 

Subphrenic  Abscess. — The  expression,  subphrenic  abscess,  is  applied  to  a 
collection  of  pus  of  greater  or  lesser  extent  located  immediately  beneath  the 
diaphragm  at  either  side.  A  subphrenic  abscess  may  be  extraperitoneal  or 
intraperitoneal  according  to  the  relations  of  the  serosa  at  the  seat  of  pus  col- 
lection. These  abscesses  arise  from  various  causes,  and  nearly  half  of  them 
are  the  result  of  lesions  of  the  stomach,  duodenum,  c«cum,  appendix,  liver, 
and  biliary  passages,  and  in  the  order  mentioned.  Aspiration  and  incisio7i 
are  the  plans  of  treatment  employed.  Aspiration  as  a  means  of  treatment 
needs  only  to  be  mentioned  that  it  may  be  the  more  forcibly  condemned,  for 
the  attempt  to  cure  by  this  procedure  is  quite  hopeless  and  should  not  be 
tried.  Aspiration  only  for  diagnostic  purposes  is  admissible.  Abdominal 
incision,  or  the  thoracic  incision  with  or  without  rib  resection,  can  be  prac- 
ticed, according  to  the  demands  of  the  case. 

The  Abdominal  Incision. — The  abdominal  incision  is  made  at  the  epigas- 
tric, hypochondriac,  iliac,  or  lumbar  region,  as  may  suit  best  the  demands  of 
safe  approach  to  the  abscess  and  the  requirements  of  subsequent  drainage. 
In  any  one  of  these  incisions  the  technique  of  approach  and  entrance  to  the 
abscess  contemplates  the  steps  preventing  infection  and  the  securing  of 
ample  drainage,  as  in  abscess  elsewhere  in  the  peritoneal  cavity. 

llie  Operation. — After  proper  aseptic  preparation  the  incision  is  usually 
made  at  the  most  prominent  part  of  the  tumor,  or  at  the  point  nearest  to 
the  pus,  through  the  respective  tissues  down  to  the  abscess.  If  adhesions 
be  present,  the  opening  of  the  abscess  and  the  evacuation  of  its  contents, 
though  simple  matters,  should  be  carefully  conducted.  The  serous  mem- 
brane should  be  shut  out  of  the  operation  field  with  a  gauze  tamponade  be- 
fore the  abscess  is  incised  ;  and  even  when  properly  done  subsequent  changes 
in  the  relation  of  the  parts,  due  to  liberation  of  the  pus,  movements  of 
the  patient,  and  the  natural  disadvantages  of  prolonged  drainage  and  its 
bad  influence,  expose  the  patient  to  manifold  dangers.  In  all  anterior  inci- 
sions a  more  dependent  drainage  than  the  primary  incision  offers  should  be 
established,  if  possible.     In  the  absence  of  ability  to  arrange  this  provision 


894 


Ui'EUATIVE   SURGERY. 


large  drainage  tubes  should  be  introduced  and  tlie  discharge  facilitated  by 
the  position  of  the  patient  when  expedient.  The  accepted  local  treatment 
for  abscess  repair  at  other  situations  is  practiced  in  these  with  such  variation 
as  circumstances  may  require.  If  the  abscess  be  accessible  to  the  lumbar 
incision  for  exposure  of  the  kidney,  or  to  the  incision  for  removal  of  the 
appendix  vermiformis,  then,  indeed,  the  technique  of  approach  and  subse- 
quent drainage  differs  from  these  operations  in  no  essential  regard.  It  is 
obvious  at  once  that  these  are  the  most  satisfactory  of  all  the  abdominal 
incisions,  and  should  be  practiced  when  feasible. 

TJie  Thoracic  Incision  [MidaxiUary  Line). — The  thoracic  incision  is 
commonly  made  across,  but  sometimes  anteriorly  to  the  midaxillary  line. 
The  technique  is  substantially  similar  in  each  instance.  After  thorough 
aseptic  care,  place  the  patient  on  the  back  near  to  the  side  of  the  table ; 
administer  chloroform  or  ether  as  the  indications  suggest;  7nahe  an  inci- 
sion across  the  midaxillary 
line  three  or  four  inches  in 
length  2~''^i''*'ll'3l  with  and 
down  to  the  selected  rib ; 
expose  and  resect  the  rib  as 
in  empyema  (Fig.  1248)  ; 
incise  the  costal  pleura ; 
pack  the  borders  of  the 
wound  with  gauze  to  pre- 
vent pleuritic  infection  ;  if 
pus  be  not  present  there, 
ascertain  with  the  needle 
its  situation ;  liberate  the 
pus  by  separating  the  tis- 
sues along  the  course  of  the 
needle  with  forceps  or  blunt 
scissors ;  interrupt  the  flow 
occasionally  with  a  sponge 
to  prevent  unpleasant  symp- 
toms; introduce  the  finger 
or  a  spoon  into  the  abscess 
and  remove  necrosed  tissue 
if  the  condition  of  the  pa- 
FiG.  1090.— Operation  for  exposure  of  subdiaphragmatic  tient  will  permit;  arrest 
space  and  of  liver  anteriorly  to  the  midaxillary  line.     ,  ,  ,       , 

«.  Seventh  rib.  J.  External  intercostal  muscle,  c.  hemorrhage,  and  cleanse 
Intercostal  vessels  and  nerve,  d.  Liver,  e.  Perito-  the  cavity  with  hot  saline, 
nfeum.    /.  Eighth  rib.     (j.  Diaphragm.     /(.  Parietal  .  ,     ,,      uipi.ioridp  solu- 

pleura.     i.  External  oblique  muscle.  ^^  ^^^^'^   ^"®  blClilOllUe  solu- 

tions if  offensive  ;  stitch  the 
edges  of  the  diaphragmatic  opening  to  the  skin  if  practicable;  pack  the 
abscess  cavity  with  gauze  if  it  is  small,  introduce  a  three-quarters-of-an-inch 
drainage  tube  if  it  is  capacious;  cover  with  abundant  gauze  held  in  position 
with  a  binder,  and  cause  the  patient  to  lie  on  the  affected  side.  Irrigation 
of  the  abscess  cavity  is  avoided  and  the  tube  shortened  to  keep  pace  with  its 


ol'KUA'I'lo.NS   ON    \lS(i;iiA    ( 'ON'N  !•:(  "I'llD    WITH    I'liliri'oN  J-ll'M.     ^*j:, 

lieiiling.  Jf  excision  be  made  loiteriurhi  to  I  he  iiiidnxilUivy  line,  ihu  incision 
is  commonly  located  between  the  seventli  ami  cigiith  ribs,  portions  of  one  or 
both  of  which  may  be  removed.  Carry  the  incision  oljlifjiiciy  forward  between 
the  ribs  (Fiy.  lU'JO) ;  expose  and  divide  the  external  oblique  muscle,  detach- 
ing it  from  the  ribs ;  resect  portions  of  one  or  more  of  the  exposed  ribs  and 
the  intervening  soft  })arts,  ligaturing  the  vessels  at  either  end  ;  expose  and 
dissect  olT  the  thin  intrathoracic  fascia,  uncovering  the  pleura  ;  press  together 
and  unite  with  sutures  the  layers  of  pleura,  if  haste  is  required,  if  not,  divide 
the  outer  layer  and  pack  the  wound  to  cause  adhesions,  and  then  later  resume 
by  dividing  the  inferior  layer,  thus  revealing  the  diaphragm  ;  observe  that 
its  fibers  run  downward  and  forward ;  separate  and  draw  them  apart,  dis- 
closing the  parietal  i^eritonaium  as  it  rests  on  the  convex  surface  of  the  liver. 
If  the  operation  be  for  abscess  or  hydatid  cyst  of  the  liver,  open  with  tro- 
car, cautery,  or  knife  at  once  if  adhesions  be  present,  if  not,  and  time  will 
permit,  i^ack  the  wound  and  open  two  or  three  days  later.  If  the  case  be 
urgent,  sew  together  the  parietal  and  visceral  layers  of  peritongeum  and  open 
immediately,  as  before.  If  subphrenic  abscess  be  the  object  of  the  operation, 
open  the  abdomen  at  once  ;  otherwise  the  methods  are  alike.  Lange^  instead 
of  dividing  the  pleura,  goes  under  it  by  peeling  it  off  the  diaphragm. 

If  pus  be  present  in  the  pleural  cavity  it  is  evacuated,  and  the  subphrenic 
collection  liberated  and  removed  the  same  as  before. 

llie  Comments. — Pyothorax  and  subphrenic  abscess  are  frequently  asso- 
ciated, the  former  being  a  sequel  to  the  latter.  The  proper  seat  of  operation 
is  established  best  by  the  aspirating  needle,  which  is  employed  as  well  during 
the  operation  for  the  better  localization  of  the  pus.  Either  the  eighth, 
ninth,  or  tenth  rib  is  selected  for  incision,  as  a  rule — the  highest  of  the  three 
in  complicating  empyaema,  the  lowest  in  subphrenic  abscess  alone.  In  sub- 
phrenic abscess  the  lumbar  and  iliac  routes  are  the  best  ones ;  the  Literal 
thoracic  is  next  in  order ;  the  anterior  thoracic  and  abdominal  the  most 
objectionable  of  all.  The  location  of  the  origin  and  the  extent  of  the  abscess 
usually  determine  the  availability  of  the  respective  routes. 

Tlie  Results. — The  earlier  the  diagnosis,  the  more  favorable  is  the  out- 
come of  the  case.  Spontaneous  healing  is  rare,  occurring  in  less  than  6  per 
cent  of  the  cases.  The  death  rate  is  estimated  from  50  (Maydl)  to  82.5  per 
cent  (Scheurlen).  However,  an  early  diagnosis,  followed  by  prompt  treat- 
ment with  improved  technique,  will  no  doubt  produce  greatly  improved 
results. 

Paracentesis  Abdominis. — Paracentesis  abdominis  is  an  operation  em- 
ployed to  remove  fluids  from  the  peritoneal  cavity.  It  should  be  recog- 
nized at  the  outset  that  the  procedure  is  not  entirely  devoid  of  danger. 
Aspirators  and  trocar  and  cannula  are  each  emplo3'ed  for  the  purpose. 

The  abdominal  wall  should  be  thoroughly  cleansed  in  advance  of  the 
operation,  and  be  protected  with  gauze.  The  strength  and  fortitude  of  the 
patient  to  meet  the  requirements  of  tlie  operation  should  be  carefully  esti- 
mated in  advance,  and  the  forces  fortified  with  the  necessary  stimulants. 
The  agent  of  puncture  should  be  thoroughly  smooth,  sharp,  and  aseptic 
before  introduction.     The  bladder  and  rectum  should  be  empty,  and  the 


890 


OPERATIVE  SURGERY. 


abnormal  line  of  dullness  of  the  abdomen  carefully  determined  by  percus- 
sion immediately  before  the  puncture  is  made.  Tlie  belly  of  the  patient  is 
then  surrounded  by  a  broad,  many-tailed  bandage,  having  a  small  opening 
in  the  center  corresponding  to  the  point  of  pro])osed  puncture.  If  unable 
to  sit,  the  patient  is  caused  to  lie  upon  the  side  near  to  the  edge  of  the  bed. 
If  the  condition  of  the  patient  will  permit,  he  may  be  placed  in  an  ordinary 
chair  with  the  body  bent  forward  and  the  head  and  arms  resting  on  the 
back  of  a  chair  placed  in  front.  If  a  small  rocking  chair  be  employed  for 
this  purpose,  the  patient  can  be  easily  and  quickly  tipped  backward  into  the 
recumbent  position  if  syncope  be  imminent  during  the  removal  of  the  fluid. 
The  injection  of  a  weak  solution  of  cocaiii  at  the  seat  of  operation  will  meet 
the  full  ana3sthetic  demands  of  the  act  (Fig.  1091). 


Fig.  1091. — Instruments  employed  in  paracentesis  abdominis,  thoracentesis,  tapping 

])ericardium,  etc. 
a.  Emmet's  trocai'.     &.  Rectal  trocar,     c.  Duncan's  trocar,     d.  Nest  of  trocars,  assorted 
sizes,     e.  Common  trocar.    /.  Fitch's  aspirating  protected  pointed  trocars,  assorted 
sizes,     g.  Billroth's  aspirating  trocar.     //.  Aspirating  syringes.     Other  forms  of  aspi- 
rators may  be  employed.     Figs.  1093  and  1246. 


The  Operation. — Carefully  localize  the  proper  scat  of  puncture  by  per- 
cussion, and  estimate  the  thickness  of  the  abdominal  Avail ;  adjust  the  slit  in 
the  bandage  to  correspond  to  the  point  of  introduction ;  seize  the  instrument 
firmly  with  the  index  finger  so  placed  on  the  upper  surface  as  to  limit  the 
extent  of  the  introduction  (Fig.  1092) ;  push  the  instrument  quickly  into 
the  abdomen  and  withdraw  the  trocar, leaving  the  cannula  in  place;  tighten 
the   bandage  as  the  fluid  escapes,  to  facilitate  the  flow  and  support  the 


()1M:K.\'1'1(>NS   ox    NISCMKA    CONMOCi'l':!)   WITH    I'KUIToX.lir.M.     S!»7 


Fi(i.  1092. — Tlie  operation  of  paracentosi.s  abdominis 
with  trocar. 


paliiMil  ;  I'ciiinvc  llic  caiiiiiihi  as  suuii  as  the  lluid  has  cscapcil,  and  when 
syncojic  is  iinjiciulini;-  and  further  withdrawal  at  this  time  is  iinpi'ucticable  ; 
\  close  the  j)unetiirc  with  iin  iii- 

terniptod  deep  sutui'e  of  cat- 
gut, and  dress  tin;  ])ai-t  with 
gauze  held  in  place  with  a 
bandage. 

Tlie  Precautions.  —  Care- 
fully avoid  puncture  of  a  dis- 
tended bladder  or  nterus  and 
of  a  displaced  or  enlarged  vis- 
cus.  If  the  ])nncture  be  made 
too  near  the  line  of  dtdlness, 
or  the  instrument  be  misdi- 
rected, the  intestines  may  be 
wounded.  Carefully  avoid 
pnnctnre  of  the  abdominal 
wall  at  the  established  site  of  significant  blood-vessels.  The  plngging  of 
the  needle  or  cannula  by  fibrin  is  relieved  by  the  introduction  of  a  probe, 
causing  dislodgment  of  the  ob- 
struction. As  the  fluid  escapes, 
the  intra-abdominal  end  of  the 
instrument  should  be  so  changed 
in  its  direction  from  time  to 
time  as  to  avoid  impingement 
on  the  intestines,  especially  if 
this  extremity  be  pointed.  Air 
should  not  be  permitted  to  en- 
ter the  abdominal  cavity.  The 
fluid  should  be  removed  slowly 
to  avoid  needless  danger  of  syn- 
cope, therefore  the  caliber  of 
the  instrument  should  not  be 
large. 

Tlie  Remarks.  —  Usually  a 
slight  incision  of  the  skin  is 
made  at  the  seat  of  puncture, 
but  if  the  puncturing  agent  be 
sharp  this  step  is  not  requisite. 
It  is  not  unwise  to  introduce  a 
small  needle  at  the  outset,  and 
perhaps  wdtli  a  hypodermic 
syringe  attachment,  to  more 
safely  locate  the  fluid  before 
the  larger  instrument  is  jjlunged 
into  the  abdomen.  Usually  the  puncture  is  made  in  the  median  line  mid- 
way between  tlie  navel  and  the  pubes.      If  the  uterus  be   distended,  the 


109:3. — Potain's  aspirator. 


898  OPERATIVE   SURGERY. 

puncture  can  be  made  at  either  side  througli  the  semilunar  line  or  in  the 
median  aspect  above  the  limit  of  distention,  as  circumstances  suggest.  The 
many-tailed  bandage  is  tightened  as  the  fluid  escapes,  and  is  confined  in 
place,  after  the  withdrawal,  for  three  or  four  days. 

HERXIA    OF   THE    AJ5D0MIXAL    WALL. 

Abdominal  hernia  is  a  protrusion  of  a  portion  of  the  contents  of  the 
abdomen  through  an  opening  in  its  wall,  surrounded  by  more  or  less  of  the 
tissues  forming  the  wall.  With  but  few  exceptions  hernire  possess  a  sac,  and 
this,  in  every  case,  is  of  the  parietal  peritoneum  (Fig.  1094).  Only  those 
viscera,  such  as  the  caput  coli,  colon,  bladder,  pancreas,  etc.,  that  are  not  nor- 
mally surrounded  by  peritonfeum,  can  form  hernia  without  a  sac.  The  con- 
tents (Fig.  1095)  of  a  hernial  sac  usually  consist,  either  singly  or  conjointly, 


Fig.  1094. — The  sac  of  abdominal  hernia.  Fig.  1095. — A  sac,  with  intestinal  contents. 

of  small  intestine  and  omentum  (Fig.  1113).  The  normal  appearance  of  the 
omentum  and  small  intestine  should  be  given  a  careful  study,  that  the 
surgeon  may  be  able  to  determine  the  various  degrees  of  change  in  their 
appearance  when  subjected  to  the  different  influences  associated  with  hernial 
protrusion.  The  granular  appearance  of  the  omental  fat,  together  with  its 
pale  color  and  extra  fibrous  structure,  will  distinguish  it  from  the  subserous 
tissue  fat.  The  omentum  and  gut,  while  in  the  sac,  usually  bear  the  same 
comparative  relation  to  each  other  as  in  the  abdominal  cavit}'^,  the  former 
being  in  front.  The  sac  has  a  neck  and  a  body,  the  shape  and  size  of  the 
latter  depending  upon  the  amount  and  density  of  the  surrounding  tissues 
and  the  nature  and  compactness  of  the  contents.  The  neck  is  the  constricted 
portion,  and  corresponds  in  size  to  the  opening  through  which  it  escapes,  its 
dimensions  being  governed  by  the  density  of  the  tissues  surrounding  it,  the 
age  of  the  protrusion,  degree  of  traction,  and  compressibility  of  the  con- 
tents. A  knowledge  of  the  normal  characteristics  of  the  peritona?um  is 
essential.  Its  rough  outer  and  smooth  inner  surface,  the  peculiar  arrange- 
ment of  its  vessels  and  its  transparency,  should  be  understood.  It  must  not 
be  forgotten,  however,  that  the  physical  appearance  of  the  sac  and  contents 
become  changed  when  long  subjected  to  the  vicissitudes  attending  hernial 
protrusions. 

The  tissues  composing  the  wall  of  the  protrusion,  called  the  "  coverings 
of  hernia,"  vary  according  to  the  situation,  the  direction,  rapidity  of  develop- 
ment, and  size  of   the  hernia.     While   these   tissues   may  readily  be   dis- 


OlMlltATIONS   ()\    VISl'KllA   lONNKC  TKI)    WI'I'II    I'lllMToXJll'M.     890 

tiiiixuislied  as  component  ])iirts  of  a  iiorniiil  uljdoininal  wall,  yet,  when 
covering  the  body  of  a  hernia  and  more  or  less  changed  fi'om  the  elTects  of 
pressure  and  extraneous  intluences,  they  often  become  ditticult  of  recognition. 

In  a  recent  hernia  the  cellular  tissues  and  fat  vary  but  little  in  appear- 
aiict'  from  the  normal  condition  ;  in  an  old  hernia  tliese  tissues  are  niucli 
thinner  than  in  the  former.  In  a  recent  protrusion  the  muscular  fibers  of 
the  cremaster  are  exceedingly  sparse  and  ill  developed,  while  in  the  older 
the  influence  of  traction  leads  to  a  marked  development  of  them,  which  is  of 
great  diagnostic  im})ortance,  as  bearing  on  the  progressive  depth  of  the 
operation  incisions  and  the  variety  of  the  ])rotrusion.  The  normally  trans- 
parent sac  often  becomes  more  or  less  opaque,  and  scarcely  distinguishable 
from  the  tissue  lying  upon  it. 

It  can  be  properly  said  that  the  changes  in  the  appearance  and  the 
anatomical  relations  of  the  component  parts  of  a  hernia  may  be  so  manifold 
that  it  will  often  present  as  varied  and  perplexing  problems  for  a  speedy 
solution  as  any  other  morbid  condition  of  the  body. 

The  operations  applicable  to  the  cure  of  the  various  abdominal  herniie 
are :  for  strangulated  hernia,  taxis  and  division  of  the  constriction ;  for  the 
reducible  hernia,  the  operation  for  radical  cure ;  for  simple  irreducible  and 
obstructed  forms  of  hernia,  the  liberation  of  the  contents  and  their  return 
to  the  proper  situation  and  retention  by  radical  metliods. 

Strangulated  Hernia. — In  strangulated  hernia  a  constriction  located  at 
the  neck  or  within  the  sac  itself  causes  obstruction  of  the  circulation  entirely 
or  in  part,  tliereby  exposing  the  affected  portions  to  the  danger  of  gan- 
grene. The  operations  for  relief  of  strangulation  are  taxis  and  herniotomy, 
the  latter  sometimes  being  called  kelotomy,  and  in  common  parlance  "  an 
operation  for  strangulated  hernia." 

Taxis. — Taxis  consists  in  returning  the  strangulated  viscus  by  manipula- 
tion through  the  channel  of  escape,  aided  by  force  of  gravity  and  relaxation 
of  the  constricting  agencies,  to  the  abdominal  cavity.  As  a  rule,  strangula- 
tion occurs  in  protrusions  of  long  standing,  where  the  patient  is  self- 
educated  in  the  practice  of  reduction.  It  therefore  follows,  when  the  case 
is  brought  to  the  attention  of  the  surgeon,  that  the  patient  has  made  persist- 
ent but  ineffectual  efforts  to  reduce  it.  Under  these  circumstances  the  out- 
look for  the  surgeon's  success  at  reduction  is  not  brilliant.  He  should 
determine,  first,  the  variety  of  the  hernia,  so  that  his  efforts  may  be  intelli- 
gently directed ;  also  its  condition,  that  the  efforts  may  not  injure  the  parts 
or  lead  to  harmful  procrastination.  If  moderate  attempt  is  not  sufficient  to 
reduce  a  strangulated  hernia,  a  hypodermic  injection  of  morphin  may  be 
given  at  once  near  the  seat  of  the  constriction,  and  the  patient  put  in  a 
warm  bath,  with  the  pelvis  elevated,  and  kept  there  until  the  combined 
influences  of  these  measures  are  felt  on  the  general  system.  Thus  the  pro- 
trusion can  often  be  returned  without  serious  difficulty  by  either  the  patient 
or  surgeon,  the  former  being  less  liable  to  employ  harmful  force  because  of 
the  pain  produced.  If  these  measures  fail,  an  anesthetic  should  be  given, 
with  the  understanding  that  a  failure  at  reduction  then  will  be  followed  by 
an  immediate  operation. 
63 


900 


OPERATIVE   SURGERY. 


Taxis  is  practiced  by  relaxing  the  tissues  contributing  to  the  constrictiou, 
and  endeavoring  to  return  the  part  of  the  hernia  first  which  escaped  last,  in 
the  direction  of  the  cliannel  through  which  it  appeared.  For  this  purpose 
empty  the  bowels  and  bladder;  raise  the  pelvis,  flex  the  thighs  upon  the 
body  and  so  abduct  and  rotate  them  as  to  properly  relax  the  tissues  about  the 
groin  and  abdomen,  grasp  the  tumor  with   the  right  hand,  and  draw  it 

downward  carefullv  to  disengasfe  its 
neck  and  at  the  same  time  to  give  to 
it  the  proper  direction  for  reduction, 
(ientle,  uniform,  and  continuous  pres- 
sure is  then  made  upon  it  with  the 
right  hand,  while  the  thumb  and  fin- 
gers of  the  left  steady  its  upper  ex- 
tremity. 

The  Precautions. — The  sac  and 
contents  (Fig.  1096)  may  be  bruised 
or  ruptured  from  too  frequent  or  forci- 
ble manipulation.  The  protrusion 
may  be  reduced  en  masse  (Figs.  1007 
and  1098),  followed  by  the  continuation  or  recurrence  of  the  symptoms  of 
strangulation.  Incision  at  the  seat  of  strangulation  or  in  the  median  line  of 
the  abdomen  offers  the  only  chance  of  relief  in  this  condition.  Taxis  should 
not  be  practiced  if  the  hernia  has  been  irreducible ;  if  symptoms  of  inflam- 
mation, gangrene,  or  general  peritonitis  be  present ;  and  if  tlie  strangulation 
be  of  longstanding — twenty-four  hours — and  have  been  frequently  subjected 
to  manipulative  attempts. 

If  taxis  is  to  be  successful,  after  a  brief  trial  the  surgeon  will  be  con- 
scious of  a  slight  gurgling  noise,  followed  by  a  diminution  in  the  size  and 
tension  of  the  tumor  caused  by  the  escape  into  the  bowel  above  of  gas  or 
faecal  matter,  which  will  soon  be  followed  by  the  return  of  the  entire  protru- 
sion. In  omental  hernia  the  gurgle  will  be  absent  for  obvious  reasons. 
Properly  directed  taxis  should  not  be  continued  longer  than  five  or  ten 
minutes,  and  if  improperly  directed,  the  sooner  stopped  the  better. 


Fig.  1096. — Strangulated  hernia  and  sac, 
awaiting  reduction  bv  taxis. 


Fig. 


1097. — Strangulated  hernia,  indirect 
reduction  en  masse. 


Fig.    1098. — Strangulated   hernia,   direct 
reduction  en  masse. 


In  taxis  for  the  relief  of  a  complete  femoral  protrusion,  it  must  not  be 
forgotten  that  it  is  first  necessary  to  press  downward,  and  then  backward 
and  -upward.  It  not  infrequently  happens  that  a  large  high  femoral  hernia 
is  mistaken  for  an  inguinal,  and  therefore  the  efforts  at  reduction  are  directed 


OPERATIONS   ON    VISCKKA    CONNKCTKD    Wl'I'H    I'lllHTOX j;r>r.     (Mil 

to  returniiiij;  it  thi-ough  the  iii<jjuiii;il  ciuiul,  a  inunifcstly  impossible  and 
unfortunate  ])ro])usition. 

TJie  liesults. — All  cases  of  strangulation  die  if  unrelieved.  Taxis  gives 
a  death  rate  of  5.8  per  cent  in  inguinal  and  about  IT)  j)er  cent  in  femoral 
hernia'. 

Herniotomy. — Tlie  steps  of  tlie  operation  of  herniotomy  may  be  logically 
divided  into  six:  1,  preparation  of  the  patient  and  division  of  the  tissues; 
2,  recognition  of  the  sac ;  3,  opening  of  the  sac ;  4,  examination  of  the  con- 
tents; 5,  division  of  the  stricture  and  return  of  the  protrusion;  G,  closure 
of  the  wound. 

The  Preparation  of  the  Patient  and  Division  of  the  Tissues. — After  the 
parts  are  shaved  and  cleansed  by  scrubbing,  and  suitably  placed  in  a  good 
light,  and  the  patient  etherized,  an  incision  two  or  three  inches  in  length  is 
made  through  the  integument,  by  transfixion,  or  direct  division  in  the  long 
axis  of  the  tumor.  The  remaining  structures,  forming  the  wall  of  the  sac, 
are  often  picked  up  one  after  another  ■with  the  thumb  forceps  at  the  lower 
angle  of  the  wound  and  nicked,  the  grooved  director  is  pushed  beneath  each 
one  successively,  and  it  is  then  divided  with  the  scalpel  or  scissors.  Free- 
hand division  of  the  tissues  without  the  use  of  the  grooved  director  is  proper 
practice  for  those  whose  knowledge  of  anatomy  and  whose  educated  sense 
of  touch  will  warrant  it ;  but  the  less  experienced  will  find  that  more  per- 
sonal comfort  and  better  results  will  follow  the  wise  ernployment  of  the 
director  than  with  the  adoption  of  the  ways  of  the  more  experienced.  The 
possibility  of  recognizing  the  different  layers  of  hernia  will  depend  very 
largely  on  the  length  of  time  the  hernia  has  existed,  as  well  as  upon  the 
amount  of  external  irritation  to  which  it  has  been  subjected.  It  is  excep- 
tional, however,  when  the  muscular  layers  and  the  deej)  fascia  can  not  be 
easily  recognized.  The  sac  is  recognized  by  its  relation  to  the  various  over- 
lying tissue  planes  of  special  significance ;  the  fascia  transversalis,  which 
covers  and  is  separated  from  it  by  the  fatty  subserous  tissue,  is  quite  liable 
at  first  to  be  mistaken  for  the  laeritona^um.  This  fascia  is  dense,  opaque, 
non-translucent,  and  always  present.  If  in  the  course  of  operation  a  similar 
tissue  has  not  yet  been  divided,  this  one  can  not  be  the  sac.  A  minute 
opening  should  be  made  through  it  at  the  lower  portion  of  the  wound,  a 
grooved  director  passed  beneath  it,  and  its  division  carefully  made.  The 
next  layer  is  the  subserous  fat,  which  is  often  quite  well  marked.  If  the 
surgeon  divides  the  fascia  transversalis  under  the  impression  that  it  is  the 
sac,  he  will  then  mistake  the  subserous  fat  for  omentum  in  the  protrusion. 
This  fallacy  will  be  quickly  dispelled,  however,  when  he  attempts  to  find  the 
intestine,  or  to  return  the  supposititious  omentum  to  the  abdominal  cavity. 

The  Recognition  of  the  Sac— The  sac  is  globular  in  form,  of  a  bluish 
color,  tense,  and  often  transparent.  A  sense  of  fluctuation  is  frequently  dis- 
cernible at  its  lower  portion.  It  can  be  pinched  up  between  the  thumb  and 
finger,  and  its  smooth  serous  surfaces  can  be  rubbed  together,  if  they  be  not 
adherent  to  the  contents.  This  manifestation  is  diagnostic.  Before  the  sac 
is  opened,  the  intestine  may  be  pinched  up  in  the  same  manner,  but  it  will 
quickly  and  easily  escape  the  grasp  because  of  the  smooth  opposed  serous 


902 


OPERATIVE   SURGERY. 


surfaces.     If  a  small  hollow  needle  be  introduced,  a  drop  of  fluid  will  escape ; 
this  is  characteristic  of  a  hernial  sac. 


Fig.  1099. — Instruments  employed  in  herniotomy. 

Large  and  small  scalpel,  b.  Hernia  bistoury,  c  Curved,  probe-pointed  bistoury,  d. 
Hernia  director,  e.  Common  director.  /.  Curved  and  straight  scissors.  /(.  Dis- 
secting and  mouse-tooth  forceps,  i.  Kangaroo  tendon  in  glass  tube.  /,  I.  Blunt  and 
hooked  retractors,  k,  m.  Tenaculum  and  blunt  hook.  n.  Silver  probe,  o.  Needle 
holder,  p.  Traction  loops,  q.  Small  clamp  and  small  needle  carrier,  r.  Curved  and 
straight  needles,  s.  Chromicized  catgut  and  silkworm  gut.  Good  light  is  very 
important. 


opp:kati()ns  on  viscera  connected  with  peritonaeum.   003 


Fi/KiUi/,  if  llic  iiiembnine  be  exiuuiuod  it  will  bo  foiiiid  lo  surround  and 
limit  tlu'  })rolrusion,  being  movable  only  as  a  whole,  is  denser  than  the  intes- 
tine, and  devoid  of  an  external  serous  surface.  The  sac  is  picked  up  with 
the  thumb  forceps  at  the  lluctuating  point  or  the  point  where  the  drop  of 
fluid  escaped,  and  a  small  slit  is  made  in 
it  with  the  knife  point  held  at  right 
angles  to  the  forceps  (Fig.  1100).  If 
fluid  be  present  it  will  then  escape.  A 
grooved  director  is  inserted,  and  an  open- 
ing made  of  sufficient  size  to  admit  the 
index  finger,  which  is  introduced  to  de- 
termine with  certainty  the  tissue  just  cut, 
and  also  the  location  of  the  constriction. 
If  the  finger  be  in  the  sac,  it  will  come 
in  contact  with  smooth  surfaces  on  all 
sides,  and,  after  division  of  the  constric- 
tion, it  can  be  passed  through  the  neck 
of  the  sac  into  the  abdomen.  If  the 
finger  be  outside  the  sac  serous  surfaces 
will  be  absent,  and  the  finger  can  not  be 

passed  upward.  The  existence  of  cyst  constrictions  of  the  sac  (Fig.  1101), 
or  a  double  sac  (Fig.  1102),  in  the  line  of  incision  may  confuse  the  surgeon  ; 
however,  if  the  finger  be  introduced  into  them  in  turn,  their  non-serous 
lining  and  the  limited  extent  of  each  variety  will  expose  the  fallacy.  The 
sac  is  opened  sufficiently  to  expose  its  contents  to  a  careful  scrutiny  in  order 
that  their  condition  may  be  carefully  considered. 

The  Examination  of  the  Contents. — Unless  contraindicated,  the  con- 
stricted point  should  be  divided  at  once  after  exposure  of  the  contents  of 
the  sac,  in  order  to  relieve  the  strangulation  and  thus  enable  the  surgeon  to 
estimate  its  influence  on  the  integrity  of  the  gut.     Under  all  circumstances 


r 


Fig.  1100. — The  operation  of  herni- 
otomy.    Nicking  hernial  sac. 


Fig.  1101. — Cystic  constriction  of  hernial  sac.        Fig.  1103. — A  double  liernial  sac. 


there  will  be  more  or  less  injection  of  the  vessels  in  strangulation.  If  the 
constriction  be  recent  or  sliglit,  the  changes  in  the  imprisoned  tissues  will 
not  be  great ;  but  when  severe,  or  long  continued,  or  where  there  has  been 
much  handling,  the  intestine  will  be  more  or  less  purple  or  blackish,  perhaps 
with  isolated  ecchymoses  and  bathed  in  bloody  fluid.    The  color  of  the  bowel 


904 


OPERATIVE  SURGERY. 


is  not  of  as  mucli  importance  in  determining  the  presence  of  gangrene  as 
the  inability  to  restore  the  circulation  after  division  of  the  stricture  by  the 
aid  of  warm  fomentations.  If  the  bowel  be  pricked  or  slightly  scarified  and 
no  blood  flows ;  if  the  circulation  be  absent  and  the  part  becomes  cool ;  if  its 
luster  be  destroyed  and  its  structure  be  softened  and  crackling,  it  should  not 

be  returned.  If  to  all  these  be  added  the 
odor  of  gangrene,  with  the  presence  of  a 
slough,  the  intestine  should  be  opened  to 
afford  exit  to  its  contents  and  treated  with 
warm  fluid  aseptic  applications.  It  is  good 
practice  to  excise  at  once  a  circular  portion 
of  the  intestine  corresponding  to  the  gan- 
grenous part  and  unite  the  extremities,  as 
described  under  the  head  of  enterectomy 
(page  658),  if  the  state  of  the  patient  will 
permit.  If  the  omentum  be  gangrenous 
or  bulky,  ligature  it  near  the  mouth  of  the 
sac  and  cut  it  off  ;  if  not,  it  can  be  returned. 
If  the  contents  of  the  sac  be  adherent  to 
each  other  or  to  the  sac,  the  adhesions  may 
be  ruptured  if  of  recent  date.  It  is  often 
necessary,  however,  to  sever  them  with  the  knife  or  scissors,  and  in  doing 
so  the  vessels  should  be  ligatured  with  fine  catgut  as  soon  as  seen.     When 


Fig.  1103. — The  operation  of  henii 
otomy,  passing  knife  along  finger. 


Fig.  1104. — Levis's  hernia  director. 


the  adhesions  are  very  firm    and    limited,  us  much  of   the  adherent  parts 
is  dissected  off  as  practicable  and  the  remainder  returned  with  the  bowel. 

The  Division  of  the  Stricture. — 
The  constriction  may  be  divided  from 
without  or  from  within  the  sac,  the  lat- 
ter being  the  more  frequent  site  selected. 
If  from  without,  it  may  be  divided  be- 
fore or  after  the  sac  is  opened.  The 
former  plan  is  the  common  practice. 
If  the  hernia  be  small,  and  strangula- 
tion have  lasted  but  a  few  hours  with- 
out severe  symptoms,  and  be  composed 
of  intestine  alone,  the  constriction  may 
be  divided  and  contents  reduced  with- 
out opening  the  sac.  However,  it  is 
much  wiser  under  all  circumstances  to 
open  the  sac  and  thus  be  assured  of  the 
integrity  of  the  bowel.  In  division  of 
the  constriction  within  the  sac,  the  finger  is  carried  up  to  the  point  of  the 
obstruction,  followed  quickly  by  a  director  (Fig.  1099,  d,  e),  or  a  hernia  bis- 


Fici.  1105. — The  operation  of  herniotomy, 
passing  knife  along  director. 


()I»KKATI()\S   ON    VlS("KliA    CONNECTKD    WTl'II    I'HKITON/EUM.     <>(>r, 


toiiry  or  i)roltt'-{)()inti'{l  bistoiiry  (//,  r)  (tarrit'd  along  tlu;  liii<,a'r  (Fig.  1  loij). 
Division  of  tlie  constriction  can  be  readily  done  l)y  passing  beneath  the  con- 
stricting tissues  the  hernia  director  of  Levis  (Fig.  1104),  which  is  cautiously 
carried  upward  until  the  constricting  band  falls  into  the  notches  at  either 
side  of  the  groove;  a  probe-pointed  bistoury  or  the  ordinary  hernia  knife  is 
then  carried  along  the  groove,  and  the  stricture  divided  (Fig.  1105),  not 
freehj,  but  only  sulliciently  nicked  to  permit  the  return  of  the  intestine. 
In  dividing  the  constriction  the  edge  of  the  knife  sliould  be 
directed  away  from  important  vessels.  If  the  gut  be  gangrenous, 
great  caution  must  be  observed  in  cutting  the  band,  or  the  adhe- 
sions of  the  bowel  to  the  border  of  the  opening  may  give  way 
and  allow  the  gut  to  escape  into  the  abdominal  cavity.  If  ex- 
tended gangrene  be  assured  and  immediate  repair  be 
impracticable,  it  is  better  not  to  divide  the  con- 
striction, thus  exposing  the  patient  to  the  dan- 
ger of  the  return  of  tlie  gangrenous 
bowel  into  the  abdominal  cavity,  and 

also  to  the  entrance  of  discharges  from  "^  ^'■'^-  HOC.-Apparatus  for  wasliing  out 

®  till!  stoinac'li. 

the  wound.      Instead    open  the  bowel 

so  as  to  relieve  the  obstruction,  otherwise  allow  it  to  remain  undisturbed. 

The  General  Remarks. — The  field  of  operation  should  be  scrubbed  and 

shaved  widely,  the  bladder  emptied,  the  stomach  washed  out  thoroughly, 

especially  if  f cecal  vomititig  has  occurred  (Fig.  1106).      In  fact,  lavage  is 

often  very  serviceable  in  the  event  of  vomiting  from  any  obstructive  cause, 

as  it  soothes  the  stomach,  lessens  the  nausea  and  vomiting,  and  thus  obviates 


Fig.  1107. — Washing  out  the  stomach 
introduction  of  the  fluid. 


Fig.  1108.— Washing  out  the  stomach 
siphoning  out  tlie  fluid. 


the  abdominal  strain.  The  patient  can  quite  easily  be  taught  to  swallow  the 
tube  (page  593)— often  without  the  aid  of  the  finger— and  to  practice  self- 
lavage  by  repeatedly  changing  the  altitude  of  the  funnel  (Figs.  1107  and 
1108). 


[)0G 


OPERATIVE  SURGERY. 


r--. 


Fig.  1109. — Tying   off   oiiientuin.      a.  a.    Ligature 
drawn  through  omentum  in  loops,  b,  b,  b. 


A  bltie  hernial  sac  may  be  mistaken  for  the  gut,  and  attempts  at  reduc- 
tion be  persistently  made.  The  sacs  of  old  herniae  in  thin  people,  umbilical 
and  congenital  herniae  in  all,  and  the  hernije  subjected  to  long  pressure,  are 
thin  and  often  so  near  to  the  surface  that  caution  is  essential  to  avoid  injury 
of  the  gut,  especially  if  adhesion  of  it  to  the  wall  of  the  sac  be  present.  The 
fluid  in  the  sac  varies  in  character  according  to  the  condition  of  the  contents. 

IMoody  fluid  indicates  either 
j  great  degree  of   constriction 

or  violent  or  excessive  manip- 
ulation (taxis) ;  dark  and  of- 
fensive fluid  indicates  tissue 
degeneration,  gangrene,  and 
])erhaps  rupture  of  the  gut. 
The  dilatation  of  the  con- 
striction by  forcing  the  finger 
through  it  in  the  presence  of 
the  gut  should  never  be  at- 
tempted, since  the  gut  is 
bruised  by  the  act.  The  re- 
turn of  the  gut  to  the  ab- 
dominal cavity  requires  care 
and  patience.  The  mesentery  should  precede  the  gut,  as  a  rule.  The  reduc- 
tion first  of  the  part  that  came  down  last  applies  to  reduction  after  as  well 
as  before  operation.  Raising  the  pelvis  or  foot  of  the  bed  facilitates  the 
return.  The  drawing  apart  of  the  opening  with  hooks,  catching  the  borders 
of  the  sac  with  forcipressure  and  raising  them  up  in  a  funnel  shape  aid  the 
return.      Other   serviceable 

manreuvres  will  occur  to  the  _M 

surgeon  at  the  time.     The  -'M^ 

omentum  is  usually  removed  ^ 

after  ligaturing  it  in  small  .    \a.  -  ,.    ' 

masses,  and  the  stump  re- 
turned entirely  into  the  ab- 
dominal cavity  (Figs.  llOli 
and  1110).  The  leaving  of 
omentum  in  the  canal  is 
objectionable,  as  it  predis- 
poses to  volvulus  and  con- 
tributes to  the  return  of 
hernia.  If  the  gut  be  much 
discolored  and  of  doubtful 
vitality,  divide  the  constric- 
tion, withdraw  the  gut  from 
its  grasp  and  allow  it  to  remain  outside  surrounded  with  Avarm,  moist, 
aseptic  dressings.  The  amount  of  strangulated  intestine  depends  largely  on 
the  extent  of  the  protrusion.  A  short  loop  (Fig.  1111)  or  only  a  portion  of 
the  wall  (Fig.  1112)  of  the  gut  may  be  thus  involved.     If  only  a  small  cir- 


FiG.  1110.— Tving  off  omentum,     o.  Section  ligatured. 
b.  Ligature"  being  tied.     c.  Loop  for  ligaturing. 


Ul'KUATKiNS   ON    NISCKKA    lUNNKCTED    WITH    I'EKITUX J:LM.     «J(j7 

cumscribetl  spot  be  suspected,  it  may  bo  returned  just  inside  of  the  abdomen 
and  a  large  drainage  tube  introduced  into  tiie  inner  end  of  the  canal,  with 
tlie  idea  that  the  ciiances  of  final  recovery  of  both  gut  and  patient  are  im- 
proved by  the  latter  j)lan.  At  all  events,  such  seems  to  be  the  case.  If 
the  patient  be  kept  quiet  the  relation  of  the  part  to  the  internal  ring  will 
change  but  little,  if  at  all.  But,  in  the  face  of  vomiting  and  other  physical 
manifestations  that  disturb  the  relations  of  the  intestines,  the  susi)ected  })art 
niigiit  readily  become  removed  so  far  from  the  opening  and  the  tube  as  to 
cause  a  general  peritonitis  in  case  of  sloughing,  instead  of  circumscribed 
adhesion  and  discharge  through  the  tube  as  provided  for.  If  gangrene  be 
present,  and  the  patient's  condition  and  the  surgeon's  preparation  will  war- 
rant, enterectomy  should  be  practiced  as  already  described  (page  058),  and 
by  the  method  best  suited  to  meet  all  the  demands  of  the  occasion.  If 
enterectomy  be  not  advisable,  the  constriction  may  be  divided  or  not,  as 
best  suits  the  views  of  the  surgeon.  If  it  be  divided  and  the  gut  be  drawn 
down  and  stitched  in  place,  the  peritoneal  cavity  may  become  infected  at 
once  or  later.  If  the  constriction  and  gut  be  not  disturbed,  and  the  bowel 
be  so  incised  as  to  allow  the  escape  of  its  contents,  little  danger  of  infection 


Fk;.  nil. — A  strangulated  short  loop  Fig.  1112. — A  strangulated  portion  of  wall 

of  intestine.  of  intestine. 

can  arise  at  any  time.  The  latter  is  surely  the  safer  procedure  and  offers  no 
subsequent  disadvantage.  In  gangrenous  intestine  primary  resection  gives 
a  death  rate  of  from  47  (Mikulicz)  to  50  per  cent  (McCosh),  which  is  about 
25  per  cent  less  than  when  treated  by  artificial  anus. 

The  After-treatment. — As  soon  as  the  bowel  is  returned,  stop  all  hjemor- 
rhage,  unite  the  wound  with  catgut  carried  through  the  sac,  introduce  a 
drainage  tube,  apply  a  compress,  dress  antiseptically,  raise  the  foot  of  the 
bed,  and  quiet  the  patient  with  an  opiate.  If  the  condition  of  the  patient 
will  approve,  a  radical  cure  should  follow  at  once  after  reduction  of  the  con- 
tents of  the  sac. 

Strangulated  Inguinal  Hernia. — A  hernia  in  this  situation  may  be  direct 
or  indirect,  either  of  which  may  be  complete  or  incomplete.  In  the  indirect 
or  oblique  form  (Figs.  1113  and  1114)  a  complete  hernia  enters  at  the  internal 
abdominal  ring,  and  passes  downward  and  forward  in  the  canal  through  the 
external  ring.  The  constricting  agent  external  to  the  sac  may  be  located  at 
either  the  internal  or  external  abdominal  rings,  and  rarely  in  the  inguinal 
canal.  The  cutting  down  upon  the  sac,  and  detecting  and  dividing  the  con- 
striction, is  described  sufficiently  under  the  general  considerations.  If  the 
seat  of  the  constriction  be  at  the  internal  ring  it  should  be  divided  upward 
and  outward  to  avoid  the  epigastric  artery  (Fig.  1114,  c)  which  runs  along 


908 


OPERATIVE   SURGERY. 


its  iuuer  border  (Fig.  1115).  In  fact,  in  the  oblique  variety  the  incision 
upward  and  outward  is  always  to  be  made  irrespective  of  the  situation  of  the 
constriction.  The  only  fallacy  that  may  arise  is  that  of  mistaking  the  direct 
for  the  indirect  form  of  hernia.  In  recent  and  in  congenital  cases  this 
mistake  can  hardly  occur,  but  in  those  of  longer  standing,  especially  in 
acquired  oblique  hernia,  the  traction  upon  tissues  of  the  ring  at  the  neck  of 
the  sac  drags  the  ring  inward  in  front  of  the  point  of  exit  of  the  direct 
variety,  and  hence  it  is  quite  difficult  and  often  impossible  to  distinguish 
between  them.  If  the  neck  of  an  oblique  hernial  sac  be  dragged  inward,  the 
epigastric  vessels  are  pressed  directly  against  its  inner  aspect,  and  also 
encroach    uj^on  its  upper  and  lower  borders.      Under  these  conditions,  if 


Fig.  1113. 


Fig.  1114. 


Fig.  1113. — Indirect  or  oblique  inguinal  hernia,  omental  and  intestinal  contents,     a,a. 

Integument  and  superficial  fascia,     h.  Aponeurosis  of  external  oblique  muscle,     c. 

Fascia  transversalis.     d.  Sac  of  hernia,     e.  Omentum.    /.  Intestine. 
Fig.  1114. — The  anatomy  of  inguinal  and  femoral  regions,  showing  course  of  descent  of 

indirect  or  oblique  inguinal  hernia,     o.  Divided  borders  of  abdominal  muscles,     b. 

Transversalis  fascia,     c.  Deep  epigastric  vessels,     d.  Aponeurosis  of  external  oblique 

muscle,     e.  Fascia  lata.    /.  Spermatic  cord.    g.  Femoral  artery,     h.  Femoral  vein. 

i.  Sheath  of  femoral  vessels,    j.  Saphenous  vein. 

the  stricture  be  divided  agreeably  to  directions  often  given — parallel  with 
the  course  of  the  epigastric  vessels — or  even  upward  or  slightly  outward, 
these  vessels  will  be  in  danger  of  injury. 

If,  on  the  other  hand,  the  protrusion  be  of  the  direct  variety,  and  the 
incision  be  made  upward  and  outward,  under  the  impression  that  it  is  a  dis- 
placed indirect  form  of  hernia,  the  epigastric  vessels  will  then  be  exposed  to 
peril  (Fig.  1116).  It  is  readily  seen,  therefore,  that  great  caution  should  be 
employed  in  distinguishing  between  the  two  prior  to  cutting  the  constric- 
tion. It  is  practically  impossible  to  discriminate  between  them  until  the 
coverings  of  the  sac  are  examined.  The  oblique  variety  has  for  a  covering 
the  cremaster  muscle,  which  can  readily  be  distinguished  in  an  old  hernia. 
This  muscle  never  forms  the  covering  of  a  direct  hernia  except  when  it 


OPERATIONS   ON    VISCKKA    CONNECTED    WITH    PERITONAEUM.     «^()9 


Fig.  1115. — The  course  of  deep  epigastric  and  obturator 
vessels. 


passes  to  tlie  outer  side  of  the  conjoined  tendon,  wlien  its  coverings  are 

similar  to  tliose  of  the  oblique  form.     It  therefore  follows,  from  the  anatom- 
ical     relations,      that 

when     the    creniastor 

does  not  form  a  co\- 

ering  the  constriction 

should  be  divided  up- 

w^ard     and     inward — 

that  is,  away  from  the 

ejiigastric  vessels.     If 

the    ere  master    forms 

one  of  the  coverings, 

then  the   constriction 

must   be  cut   upward 

and  outward,  provided 

there  be  no  evidence 

that  it  is  a  direct  her- 
nia which  has  escaped 

to   the   outer   side    of 

the  conjoined  tendon. 

This   latter   condition 

is  fortunately  rare,  and 

this,  when    taken    in 

connection  with  the  location  of  the  tumor  at  its  incipiency,  should  settle 

the  question  between  the  two.     If,  however,  it  be  impracticable  to  settle 

the  doubt,  dull  the  edge  of  the  knife  by  draw- 
ing it  across  a  piece  of  metal,  and  then  pro- 
ceed carefully  to  nick  the  neck  of  the  con- 
striction in  an  upward  direction.  If  the  con- 
striction be  at  the  external  abdominal  ring, 
it  matters  little  in  which  direction  the  cut  is 
made  ;  however,  to  simplify  matters,  the  direc- 
tion upward  and  outward  should  still  be  ad- 
hered to.  The  methods  of  examination  of 
the  contents  of  the  sac  and  their  I'eduction, 
together  with  the  subsequent  treatment,  are 
sufficiently  considered  in  the  preceding  pages. 
If  the  protrusion  be  incomplete  the  treatment 
is  similar,  and  the  matter  simplified  by  the 
inability  to  confound  the  direct  with  the  indi- 
rect varieties  of  this  form. 

The  EesuUs. — The  general  rate  of  mortal- 
ity of  operation  for  strangulated  inguinal  her- 
nia is  about  19  per  cent. 
Strangulated  Femoral  Hernia. — The  protrusion  in  this  instance  enters  at 

the  femoral  or  crural  ring  at  the  inner  side  of  the  femoral  vein  (Fig.  1117), 

passing  between  the  vein  and  Gimbernat's  ligament,  and  the  inner  boundary 


Fig.  1116. — Direct  inguinal  her- 
nia, a.  Integument  and  fascia. 
b.  Aponeurosis  of  external  ob- 
lique muscle,  d.  Spermatic 
cord.  e.  Epigastric  vessels.  /. 
Sac.     g.  Hernial  contents. 


910 


OPERATIVE  SURGERY. 


Fig.  1117. — Transverse  section  below  Poupart's  ligament. 
a.  Anterior  superior  spine  of  the  ilium,  h.  Iliac  fascia, 
c.  Anterior  crural  nerve,  d.  Femoral  artery,  e.  Femoral 
vein.  /.  Septum  crurale.  g.  Gimbernat's  ligament,  h. 
Spine  of  pubes.  i.  Pectineal  fascia,  j.  Ilio-pectineal 
eminence,  k.  Iliac  bursa.  /.  Rectus  femoris  muscle. 
m.  Sartorius  muscle,      n.  Transversalis  fascia. 


of  the  femoral  canal  for 
about  half  au  inch,  to 
the  upper  portion  of  the 
saphenous  opening  (Figs. 
1118  and  1110),  through 
which  it  escapes ;  after- 
ward, ill  many  instances, 
it  passes  upward  and  rests 
upon  the  falciform  pro- 
cess of  that  opening  (Fig. 
1120).  The  two  common 
poi)its  of  constriction  are 
Gimbernat's  ligament 
(Fig.  1117)  and  the  sharp 
border  of  the  falciform 
process  of  the  saphenous 
opening.  The  important 
boundaries  of  the  upper  extremity  of  the  crural  canal  are,  within,  Gimber- 
nat's ligament,  and  without,  the  femoral  vein  (Fig.  1117),  surrounded  by 

its  sheath.     Throughout  the  course  of  this 
the  femoral  vein  lies  at  the  outer 
side.    The  distinctive  coverings  of  this 
protrusion  are  the  cribriform  fascia, 
crural  sheath,  and  septum 
crurale.       The    important 
vascular  relations  are  those 
of    the   femoral    vein    and 
the  obturator  artery. 

Taxis    should    be    em- 
ployed with    greater    cau- 
tion and  for  a  shorter  time 
in  femoral  than  in  ingui- 
nal hernia,  since  the  con- 
stricting     influences     are 
greater,  and    the   neck  of 
the   sac   much    smaller  in 
the  former.    The  fact 
,     is   again    referred    to 
/      that  a  femoral  hernia 
that  extends  upward 
toward  Poupart's  liga- 
ment, sometimes  reach- 
ing above  it,  may  be  mis- 
taken   for    one    of    the 
inguinal    variety ;     and, 

„  ,    ,          ,       •        u      •     .1         I  therefore,  the  elforts  at 

Fig.  1118.— Anatomy  of  the  femoral  region,  showing  through  .     '  a-       *■    ^ 

opening  in  femoral  sheath  the  relations  of  tlie  femoral  reduction  are     directed 
canal  to  the  femoral  vein  and  saphenous  opening. 


OI'KKATIONS   ON    VISCHKA    t'ON.Xi'X'TKI)    Willi    I'l  IK'IT*  )N.i:r.M.      \)\l 


M 


f, 


i 


i.  1110. — ('oiii|)k'to  femoral  hernia. 
a.  Intfffuinciit  and  fascia,  b.  A\)o- 
nenrosis  of  external  oblique  mus- 
cle, c.  Spermatic  cord.  £?.  Femoral 
vessels,  e.  Sac  of  hernia.  /.  In- 
testinal contents  of  hernia. 


to  ri'tuniiiij^  it  throujjli  the  extenml  ub- 
doiniiiiil  rin<jf  instead  of  pushing  it  chjwn- 
ward,  buckwjird,  and  upward,  as  is  neces- 
sary It)  I'lrect  a  reduction  of  tlie  former. 

The  Operation. — Tlie  field  of  operation 
shouhl  be  washed,  siiaved,  and  disinfected  ; 
the  j)atient  phiced  on  the  back,  the  thigli 
flexed  and  rotated  outward,  tlie  bhidder 
emptied,  the  patient  an;esthetized,  and  a 
vertical  incision  made  uj)on  the  tumor  in 
the  line  of  the  long  axis  of  the  femoral 
canal,  with  the  center  over  the  border  of 
the  falciform  process  (Fig.  1120).  The  in- 
tegument and  superficial  fascia  should  be 
carefully  divided,  thus  exposing  the  crib- 
riform fascia,  which  in  fleshy  subjects  is 
loaded  with  fat.  This  fascia  and  the 
glands  connected  with  it  (Fig.  1130), 
especially  if  the  latter  be  enlarged,  form 
a  mass  often  difficult  to  understand.     The 

glands  should  be  pushed  aside  and  the  remainder  of  the 
structure  carefully  divided.     It  can  hardly  be  mistaken 
for  anything  but  the  omentum,  or  the  deeper  layer  of 
fatty  tissues.     The  absence  of  the  sac 
will  readily  expose  the  former  fal- 
lacy, and  the  presence  of  the 
latter  will  soon  be  disclosed. 
The   femoral    or    crural 
sheath   comes    next  in 
order  (Fig.  1118).     It 
is    dense,  like    the 
fascia  trans ver- 
salis,  of  which 
it  is  a  prolon- 
gation,     and 
might  be  mis- 
taken for  the  sac 
did  it  not  present 
appearances  of  a  dif- 
ferent character,  which 
have  already  been  de- 
scribed.      The    septum 
crurale    (Fig.   1117)    will 
hardly   form   one   of    the 
entire  coverings  if  the  pro- 
trusion be  large;  if  it  does 
Fig.  1120. — Superficial  anatomy  of  femoral  region.  form  a  covering  it  will  be 


912 


OPERATIVE  SURGERY. 


much  diminished  in  thickness,  and  somewhat  blended  with  the  subserous 
tissue.  It  sometimes  happens  that  the  small  lymphatic  gland,  which  nor- 
mally exists  between  the  subserous  tissue  and  the  septum  crurale,  can  be  dis- 
tinguished, which,  of  course,  settles  all  doubts  as  to  the  identity  of  the  tissues 
under  inspection.  The  careful  use  of  the  knife  and  director  soon  exposes 
the  sac  with  its  characteristic  appearance.  It  should  be  opened  at  the  lower 
extremity  with  the  precautions  previously  enjoined,  and  the  stricture  sought 
for  and  divided.  If  the  stricture  be,  as  is  usual,  at  the  free  border  of  the 
falciform  process,  flex  the  thigh,  rotate  it  inward,  and  if  no  further  obstruc- 
tion exists,  the  protrusion  can  be  reduced.  If  the  constriction  be  at  the  free 
border  of  Grimbernat's  ligament,  this,  too,  must  be  nicked.  It  is  necessary 
to  recall,  before  the  nicking,  that  the  obturator  artery  once  in  three  and  a 
half  cases  arises  from  the  epigastric,  and  although  it  usually  lies  in  con- 
tact with  the  vein  in  its  descent  (Fig.  1121),  and  is  therefore  out  of  danger, 
yet  it  not  infrequently  curves  inward  along  the  free  margin  of  Gimbernat's 

ligament  (Fig.  1115),  thus  nearly  encir- 
cling the  neck  of  the  sac,  and  therefore  is 
in  great  danger  of  being  cut.  The  knife 
should  be  made  quite  dull,  and  the  liga- 
ment nicked  superficially  and  obliquely  up- 
ward and  inward  in  this  instance.  The  tip 
of  the  little  finger  may  then  perhaps  safely 
be  inserted  and  the  artery  sought  for  along 
the  posterior  surface  of  the  ligament;  if 
not  discovered,  the  nicking  may  be  repeated, 
or  firm  traction  wuth  the  finger  against  the 
ligament  may  be  made,  aided  perhaps  by  a 
hook,  so  as  to  tear  or  stretch  it.  This  ves- 
sel may  have  been  cut  ten  or  twelve  times 
in  this  operation,  but  in  each  instance  the 
bleeding  was  controlled  by  ligature  or  com- 
pression, and  the  patient  recovered.  After  returning  the  protrusion  the 
wound  is  closed  and  dressed  antiseptically. 

Femoral  herniae  do  not  always  follow  the  course  just  described  ;  they 
take,  though  infrequently,  anomalous  courses,  sometimes  appearing  at  the 
outer  side,  or  behind  the  femoral  vessels.  They  have  been  known  to  pass 
through  Gimbernat's  ligament.  It  is  important  to  know  that  in  all  the 
anomalous  cases  the  neck  of  the  sac  lies  closely  associated  with  the  epi- 
gastric artery  alone,  or  together  with  the  obturator,  and  troublesome  and 
even  fatal  hsemorrhages  may  be  caused  unless  care  is  taken  in  dividing  the 
constriction. 

The  Results. — The  general  death  rate  after  operation  for  strangulated 
femoral  hernia  is  about  24  per  cent. 

Strangulated  Umbilical  Hernia. — Umbilical  hernia^  appear  at  all  ages  of 
life  and  in  response  to  devious  causes.  The  symptoms  of  strangulation  are 
generally  acute,  although  large,  old,  and  persistent  protrusions  of  this  kind 
sometimes  do  not  cause  pronounced  manifestations. 


Fig.  1121.— The  curve  of  the  obtu- 
rator artery  and  consequent  rela- 
tion to  Gimbernat's  ligament  (*). 


urHKATlONS   ON   VISCEUA   CONNECTED  WITH    I'EIUTOX.EL'M.     913 


Tlie  Operation. — After  thorough  cleansing  of  the  surface,  make  an 
elli])tical  incision  at  the  median  line  broad  enougii  to  include  the  super- 
abundant tissue ;  deepen  the  incision  at  one  side  down  to  the  aponeurotic 
structure ;  reflect  this  half  of  the  ellipse  toward  the  median  line,  thus  expos- 
ing the  neck  of  the  sac  and  the  margin  of  the  hernial  opening  at  that  side; 
repeat  the  step  at  the  opposite  side,  thereby  isolating  the  hernial  opening, 
the  neck  and  body  of  the  sac,  the  latter  still  bearing  the  integumentary 
ellipse ;  open  the  sac  at  the  point  farthest  from  adhesions  and  at  the  lower 
bonier,  if  i)racticable ;  expose  and  examine  the  contents;  remove  omentum 
(Figs.  llUlt  ;ind  1110),  retain  and  repair  gangrenous  intestine,  enlarge  the 
hernial  orifice  above  and  below  and  return  the  sound  parts  to  the  belly; 
sever  the  neck  of  the  sac  at  the  border  of  the  hernial  opening  and  remove 
the  sac  with  the  integumentary  ellipse  ;  freshen  the  border  of  the  hernial 
opening  and  close  it  directly  by  sewing  or  after  the  method  of  radical  cure 
(page  915);  dress  the  wound,  put  the  patient  in  bed  on  the  back  for  three 
or  four  weeks.  A  supporting  pad  is  worn  for  months  after  resuming  the 
erect  posture.  If  the  condition  of  the  patient  will  permit,  a  radical  cure 
should  be  practiced  at  once.  The  constriction  should  be  divided  without 
the  sac  when  feasible,  but  the  contents  ought  not  to  be  returned  until  exam- 
ined through  an  incision  made  into  the  sac. 

I'he  Precautions. — Taxis  in  strangulated  umbilical  hernia  should  be 
practiced  with  especial  care,  to  avoid  injury  of  the  contents  of  the  sac.  If 
the  intestine  be  gangrenous,  the  constriction  causing  it  should  not  be  divided 
unless  repair  of  the  gut  is  made  at  once,  because  infection  of  the  peritoneal 
cavity  is  almost  sure  to  follow  on  account  of  the  relations  of  the  wound  to 
the  dorsal  position  of  the  patient. 

The  Results. — A  general  death  rate  of  about  5U  per  cent  follows  opera- 
tions for  strangulation.     If  prompt  ac- 
tion be  taken  a  much  better  outlook  than 
this  may  be  expected. 

Strangulated  Obturator  Hernia  (Fig. 
1122). — The  viscus  in  this  instance  fol- 
lows the  course  of  the  obturator  vessels 
in  its  escape  from  the  pelvis,  and  lies 
beneath  the  pectineus  and  obturator 
muscles.  It  is  usually  small  and  may 
not  be  detected  during  life. 

The  incision  for  its  relief  is  made  over 
the  tumor  at  the  inner  side  of  and  parallel 
to  the  femoral  vessels.  The  constriction 
has  been  found  in  the  fibers  of  the  pectin- 
eus muscle ;  and  it  is  usually  necessary 
to  divide  some  fibers  of  this  muscle  in 
order   to   expose   the    opening   through 

which  the  bowel  has  escaped.  The  relation  of  the  obturator  vessels  to  the 
neck  of  the  sac  varies,  being  equally  frequent  at  the  outer  and  inner  sides, 
never  in  front,  but  occasionally  behind  it.     If  the  constriction  be  found  at  the 


/ 


Fig.  1122. — The  relation  of  an  obtura- 
tor hernia  to  the  obturator  mem- 
brane and  vessels,  and  to  the  bone. 


914 


OPERATIVE   SURGERY. 


foramen,  it  will  require  much  caution  to  divide  it  without  implicating  these 
vessels.     Abdominal  section  has  been  practiced  in  many  instauces  of  relief. 

The  Results. — The  death  rate  is  about  80  per  cent  with  surgical  treat- 
ment, owing,  no  doubt,  to  delay  in  detection  and  diagnosis. 

Strangulated  ventral   hernia  is   treated  not  unlike  that  of  umbilical. 
Strangulated  lumbar  (Fig.  1123),  ischiatic  (Figs.  1124  and  1125),  perineal, 

and  diaphragmatic  hernitB  (page  lO.'];"))  are 
especially  dangerous  because  of  failure  of 
recognition,  if  at  all,  until  too  late  for  oj^era- 
tive  benefit. 

Retroperitoneal  Herniae. — This  variety 
of  hernia  is  rarely  determined  except  when 
revealed  by  coeliotomy  for  the  relief  of  in- 
testinal  obstruction   due   to   strangulation. 


Fig.  1123. — A  lumbar  hernia 
escaping  through  the  canal 
of  Petit. 


r^ 


Fig.  1124. — A  large  ischiatic 
hernia. 


Fig.  1125. — The  contiguous  anatomy  of  ischiatic 
hernia.  H.  The  hernia.  P.  Pyriformis  muscle. 
N.  Great  sciatic  nerve.  L.  g.  s.  Great  sacro- 
sciatic  ligament.  L.  I.  s.  Lesser  sacro-sciatic 
ligament.  The  gluteal  nerve  and  vessels  are 
seen  above  the  hernia,  and  the  sciatic  below. 


The  fossa  duodeno-jejunalis  of  Treitz  (Fig.  964),  the  subca^cal  fossa  of  the 
inner  side  of  the  caecum,  the  foramen  of  Winslow  and  the  fossa  inter- 
sigmoidalis  at  the  under  surface  of  the  meso-colon  and  sigmoid  flexure,  are 
the  most  frequent  sites  of  this  form  of  hernia,  and  occur  in  the  order  stated. 
They  may  be  small  or  large,  even  extending  to  nearly  the  whole  of  the  small 
intestine  (Fig.  1120).  The  constriction  is  relieved  and  the  point  of  escape 
enlarged  sufficiently  to  permit  of  the  withdrawal  and  proper  replacement  of 
the   intestines.     The   technique   referable   to  operations  of   the  peritoneal 


Ol'llliATloXS   ON    VISCERA   CONNECTED    WITH    I'KlilTON.EUM.     915 


cavity,  herni.il  protrusions,  aiul  repair  of   tiie  peritonanini,   will   nicct   the 
re(jiiiremeiits  of  tiiese  cases. 

Sixty-four  duodenal,  12  i)eriea?cal,  8  of  tlie  foramen  of  Winslow,  and  3 
intersiLrnioidal  hernia'  have  been  collated  by  Jonnesco. 

The  Operations  for  the  Radical  Cure  of  Hernia. — Various  operative 
methods  liave  been  devised  for  the  cure  of  hernia,  the  majority  of  Mliich 
have  not  withstood  tlie  test  of  time  and  the  ever- 
increasing  simplicity  of  oj)crative  technique.  The 
operation  for  radical  cure  of  hernia  should  be  prac- 
ticed with  much  discretion,  as  all  persons  thus 
affected  are  not  proper  subjects,  nor  are  all  hernia? 
suitable  ones  for  operation.  Elderly  persons  with 
large  hernite,  and  infirm  ones  with  hernial  protru- 
sions that  can  be  retained  in  place,  should  not  bo 
subjected  to  operation  except  for  strenuous  reasons, 
and  then  only  after  they  are  made  aware  of  the  dan- 
ger which  the  procedure  invites.  The  young  and 
vigorous  are  the  proper  subjects  for  this  treatment. 
Primary  union  without  annoyance  from  buried  su- 
tures tliercafter  are  the  local  desiderata  of  greatest 
importance.  Therefore,  rigid  asepsis  is  to  be  em- 
ployed when  possible.  Kangaroo  tendon  is  the  most 
reliable  absorbable,  and  silver  wire  the  best  unabsorb- 
able,  suture  now  in  use.  Silken  sutures  are  very 
serviceable  indeed  when  thoroughly  aseptic.  Silk- 
worm gut  and  catgut  should  be  discarded  for  this 
purpose. 

Bassini's  Method  of  Operation  {Inguinal  Hernia). — Bassini's  method  is 
comparatively  simple  and  thoroughly  efficient,  and  is  practiced  oftener  at  the 
present  time  in  this  country  than  any  other  method. 

The  Operation. — Make  an  oblique  incision  half  an  inch  above  and 
parallel  with  Poupart's  ligament  from  a  point  opposite  the  anterior  superior 
spine  of  the  ilium  to  the  crest  of  the  pubes  ;  carry  a  traction  suture  between  the 
borders  of  the  respective  flaps  and  draw  them  aside ;  expose  and  divide  on  a 
director  the  aponeurosis  of  the  external  oblique  from  the  external  abdominal 
ring  along  the  line  of  incision  for  two  or  three  inches  (Fig.  1127) ;  seize  with 
forceps  in  turn  the  borders  of  the  aponeurotic  flaps  and  separate  the  upper 
inward  to  the  outer  edge  of  the  rectus  abdominis  muscle,  and  the  lower 
down  to  and  along  Poupart's  ligament,  from  the  underlying  tissues  with  the 
finger  or  handle  of  the  scalpel,  thus  exposing  to  view  the  contents  of  the 
inguinal  canal ;  pass  traction  sutures  through  the  respective  borders  of  the 
opening  and  draw  them  aside  and  raise  eji  masse  from  the  inguinal  canal 
with  the  fingers,  aided  with  blunt  curved  scissors,  the  hernial  sac  and  the 
cord  (Fig.  1128) ;  with  the  thumbs  and  fingers  aided  with  forceps,  separate  the 
cord  and  its  vessels  from  the  sac  from  a  point  high  within  the  internal  ring 
downward  ;  open  the  sac  at  the  dependent  part,  examine  the  contents  and 
return  them  to  the  peritoneal  cavity ;  transfix  the  neck  of  the  sac  and  liga- 
04 


Fig.  1 126.  —  Retroperito- 
neal hernia  of  the  small 
intestine.  /(.  Sac  of  her- 
nia. ./.  Protruding''  loop 
of  jejiniiun.  /".  Ileum. 
c,c.c,c.  Ascending  and 
transverse  colon.  f.s. 
Sigmoid  flexure,  o,  o. 
Omentum. 


910 


OPERATIVE  SURGERY. 


ture  it  in  halves  with  strong  catgut,  and  cut  it  off  (Fig.  1129) ;  draw  back  the 
edges  of  the  aponeurotic  flaps  and  raise  the  cord  out  of  the  way ;  introduce 
beneath  the  cord  from  before  backward  and  within  outward,  or  the  reverse, 
successively  four  or  five  buried  kangaroo-tendon  sutures  connecting  Pou- 
part's  ligament  with  the  conjoined  tendon,  and  the  lower  fibers  of  the 
internal  oblique  and  transversalis  (Fig.  1130);  tie  each  snugly,  thus  joining 
directly  with  Poupart's  ligament  the  conjoined  tendon  and  a  portion  of 
the  lower  fibers  of  the  internal  oblique  and  transversalis  muscles  (Fig.  1131) ; 
replace  the  cord  and  unite  the  borders  of  the  aponeurotic  flaps  over  it  with  a 

continuous  suture  of  catgut  (Fig, 
1132) ;   close  the  integumentary 


Fig.  1137. 


Fig.  1128. 


Fig.  1127. — Operation  for  the  radical  cure  of  inguinal  hernia,  Bassini's  method,  a.  Her- 
nia and  cord.     i.  Aponeurosis  of  external  oblique  muscle,      c.  Poupart's  ligament. 

Fig.  1128. — Operation  for  the  radical  cure  of  inguinal  liernia,  Bassini's  method,  a  and  h. 
Sac  and  cord  raised  en  masse  and  held  with"  fold  of  gauze,  c.  Cord  entering  scrotum. 
d.  Pouparfs  ligament,  e.  Arched  fibers  of  internal  oblique  muscle.  /.  Transver- 
salis fascia. 


incision  without  drainage   and   dress  in  the  usual  manner,  confining   the 
dressings  in  place  with  a  hip  spica. 

The  Precautions. — Poupart's  ligament  should  be  carefully  outlined  by 
palpation  and  introduction  of  the  finger  into  the  inguinal  canal  before 
making  the  primary  incision,  to  avoid  its  misplacement.  In  transfixing  and 
tying  omentum,  do  not  forget  that  a  transfixed  vessel  will  bleed  persistently, 
and,  if  returned  to  the  abdominal  cavity,  may  cause  death  from  haemorrhage 
before  the  cause  is  suspected  ;  therefore,  examine  the  omental  stump  carefully 
for  oozing  or  insecure  ligaturing  before  its  return  to  the  cavity.  Pinching 
of  the  cord  by  approximation  of  the  tissues  in  closing  the  canal  with  buried 
sutures  is  liable  to  happen  and  should  be  avoided.  If  the  deep  epigastric 
artery  be  tortuous,  or  the  needle  be  dipped  incautiously  in  sewing,  the  vessel 
may  be  transfixed  by  the  needle,   causing  perplexing  hemorrhage.      The 


OPERATION'S   OS    VISCERA   (.'ONXECTHD    WITH    I'ERITOXyEUM.     917 


writer  once  liad  an  experience  of  this  kind.  Twisting  the  sac  is  sometimes 
])racticed,  and  serves  to  isolate  it  somewhat  more  and  define  tlie  seat  of  the 
neck.  However,  if  it  be  twisted 
too  vigorously  and  be  then  trans- 
fixed and  tied,  and  cut  otl  before 
untwisting,  the  untwisting  may 
loosen  the  ligature  and  render  it 
insecure.  Repair  is  made  in  this 
instance  by  sewing  together  with  a 
mattress  or  continuous  catgut  or 
silk  suture  the  borders  of  the  open- 
ing, the  same  as  in  other  peritoneal 
wounds.  It  is  safer  practice  to 
make  the  sac  tense  by  downward 
traction,  followed  by  upward  pres- 
sure at  its  neck  between  the  thumb 
and  fingers  to  push  away  the  con- 
tents, succeeded  by  interval  inspec-  -i>^>,iwrr.  'v:^^^ 
tion  to  note  their  absence   before 

the  neck  of    the  sac   is   transfixed.    Fig.  1129.— Operation  for  the  radical  cure  of 
T^  -ii     ii  •      1  <!  inguinal  hernia,  Bassini's  inetliod.     a.  Sac 

hxen  with  this  degree  of   care   we  dissected  from  the  cord,  opened,  examined, 

once  passed  the  needle  through  the  and  neck  ligatured.     &.  Cord.    c.  Pouparfs 

1       ^         J?  ii      •    J.     i.-  ligament.       d.  Arclied   fibers   of  internal 

mesenteric  border  of  the  intestine.  oblique  muscle,    e.  Transversalis  fascia. 

The  Remarks. — The  separation 
of  the  sac  from  the  cord  is  often  very  difficult,  especially  in  herniae  of  con- 
genital origin.     It  is  even  difficult  sometimes  to  detect  the  presence  of  the 

sac,  especially  in  recent  and  incom- 
plete herniae.  The  isolation  of  the 
sac  is  usually  best  accomplished  by 
beginning  at  its  neck  and  working 
downward.  If  the  sac  be  very  thin 
and  illy  defined,  or  difficult  of  isola- 
tion, its  presence  can  be  established 
and  isolation  facilitated  often  by 
the  introduction  into  the  sac  of  the 
finger  through  a  small  incision 
made  for  the  purpose  of  guidance 
and  sujoport.  The  separation  of 
the  sac  often  requires  great  patience 
and  much  care  to  prevent  unwise 
bruising  and  tearing  of  the  vascular 
and  fibrous  tissues,  thus  hindering 
the  prompt  union  so  essential  to 
final  success.  The  adhesions  be- 
tween the  sac  and  the  contents,  and 
between  the  contents  themselves, 
must  be  carefully  overcome,  and  the 


Fig.  1130.— Operation  for  tlio  radical  cure  of 
inguinal  hernia.  Bassini's  metliod.  Sac  re- 
moved (c),  cord  drawn  aside,  and  stitching 
of  lower  fibers  of  the  internal  oblique  and 
transversalis  muscles  {b)  to  Poupart's  liga- 
ment (d)  from  without  inward,  a.  Trans- 
versalis fascia. 


918 


OPEIIATIVE  SURGERY. 


contents  returned  to  the  abdominal  cavity  before  the  sac  is  further  treated. 
The  cord  can  be  held  out  of  the  way  easily  with  a  fold  of  sterilized  gauze 
while  tlie  buried  sutures  are  being  placed.  Before  introducing  the  kangaroo- 
tendon  sutures,  separate  with  the  fingers  the  lower  borders  of  the  internal 
oblique  and  transversalis  muscles  from  the  transversalis  fascia  and  from  the 
conjoined  tendon  outward  to  the  internal  abdominal  ring.  In  closing  the 
canal  from  within  outward,  isolate  completely  the  conjoined  tendon  and  pass 


Fig.  1131. 


Fiu.  li;^2. 


Fig.  1131. — Operation  for  the  radical  cure  of  inguinal  hernia,  Bassini's  method.  Arched 
muscular  fibers  and  conjoined  tendon  (b)  sewed  to  Poupart's  ligament  (a),  c.  Apo- 
neurosis of  external  oblique  muscle. 

Pig.  1132. — Operation  for  the  radical  cure  of  inguinal  hernia,  Bassini's  method.  Apo- 
neurosis of  external  oblique  (a)  sewed  with  continuous  sutures  to  Poupart's  ligament  (6). 


the  end  of  the  index  finger  behind  it ;  pass  a  long,  curved,  dull  needle,  armed 
with  a  kangaroo-tendon  suture,  through  Poupart's  ligament  just  outside  the 
spine  of  the  pubes;  carry  the  needle,  guided  by  the  finger,  behind  the  con- 
joined tendon,  thence  through  its  outer  border  to  the  front ;  pass  the  second 
suture  through  Poupart's  ligament  half  an  inch  or  so  external  to  the  first, 
thence  along  the  finger  beneath  the  arched  fibers  of  the  internal  oblique  and 
transversalis  muscles  half  an  inch  or  so  from  the  first,  then  forward  through 
the  tissues  to  the  front.  The  latter  stitch  is  repeated  until  the  cord  is  nearly 
reached.  Sometimes  the  muscular  fibers  beyond  the  internal  ring  are 
divided  for  about  an  inch  (Fig.  1128,  a),  and  the  cord  is  pushed  outward 
into  the  cut  to  increase  the  length  of  the  canal  and  change  the  direction 
of  the  outer  end.  If  this  be  done  an  extra  suture  is  required.  After 
closure  of  tlie  integument  the  wound  may  be  sealed  with  collodion.  The 
dressing  should  be  applied  firmly  along  the  couise  of  the  canal  and  the 
hip  spica  put  on  with  the  thigh  sliglitly  flexed,  so  that  with  extension  the 
dressings  are  drawn  firmly  into  place  and  held  there  until  the  limb  is 
flexed  aarain. 


UPKKATIONS   OX    VISCKIIA   CONNPJCTKD    WI'I'II    IMIKITUX .KLM.      l>l«j 


The  Nesnlts. — /i'(i.s,siNi  rc'{)orts  251  cases  with  7  relupsos.  Coley  reports 
514  cases  of  tliis  nietliotl  witli  5  relapses.  Coley  reports  also  GOO  cases  with 
but  a  single  death,  which  occurred  after  489  consecutive  successful  operations. 

Halsted's  Method  of  Operation  {Inguinal  Hernia). — Make  an  incision 
from  a  point  ;>  cenlinietres  (1.18  in(;hes)  beyond  and  above  the  internal 
abdominal  ring  to  the  spine  of  the  pubes  (Fig.  113.'}),  exposing  the  aponeu- 
rosis of  the  external  oblicjue  and  the  external  abdominal  ring;  divide  the 
aponeurosis  of  the  external  oblique,  the  fibers  of  the  internal  oblique  and 
transversalis  muscles,  and  the  transversalis  fascia,  to  a  point  about  an  inch 
above  the  internal  abdominal  ring  (Fig.  1134);  isolate  the  vas  deferens  and 
the  blood  vessels  of  the  cord  (Fig.  1135),  and  excise  all  the  veins  but  one 
or  two  (Fig.  llofi) ;  isolate  and  open  the  sac  and  return  the  contents  to 
the  abdominal  cavity ;  detach  thoroughly  the  upper  end  of  the  sac  and  close 
it  with  mattress  or  continuous  sewing  with  silk,  and  cut  off  the  sac  close 
to  the  sutures ;  raise  the  cord  up- 
ward and  out  of  the  way  and  in- 
troduce six  or  eight  silver-wire 
mattress  sutures  through  the  apo-  i  '\ 
neurosis  of  the  external  oblique,  "'\ 

the  muscular  fibers  of  the  internal         \  '■-■-,, 

oblique  and  transversalis,  and  the         I  '■'■•..._ 

transversalis  fascia,  at  the  upper         \  "'■■-.. 

side  and  through  the  transversalis         '  ^•/^'■•-^c 

fascia,  Poupart's  ligament,  and 
the  aponeurosis  of  the  external 
oblique  at  the  lower  side  of  the 
wwmd  (Fig.  1137).  The  two 
outermost  sutures  pass  through 
muscular  tissue  at  both  sides  of 
the  wound  and 
between 


.f'-ycv 


them 
the  cord  is  permitted 
to  escape ;  tie  the  su- 
tures so  as  to  bring 
the  tissues  snugly  to- 
gether (Fig.  1138), 
unite  the  borders  of 
the  aponeurosis  of  the 
external  oblique  mus- 
cle with  silver  -  wire 
mattress  sutures  (Fig. 
1139),  and  close  the 
skin  wound  with  a  fine  continuous  subcuticular  silver- wire  suture  (Fig.  1140). 
The  Remarks. — In  this  operation  a  new  canal  and  internal  ring  are 
formed,  the  latter  fitting  the  cord  snugly.  During  the  closure  of  the  base  of 
the  sac  by  sewing  the  intestine  is  retained  in  place  with  gauze  or  a  string- 
attached  sponge,  and  as  the  sewing  progresses  the  sac  can  be  severed,  thus 


Fig.  1133. — Operation  for  the  radical  cure  of  inguinal  hernia, 
Halsted's  method.  An  anterior  superior,  spinous  process. 
Skin  incision,  exposure  of  external  abdominal  ring  and 
the  cord;  line  of  division  of  aponeurosis  of  external 
oblicjue  muscle  (dotted  line). 


920 


OPERATIVE  SURGERY. 


maintaining  better  control  of  the  peritoneal  borders  of  the  opening.  The 
restraining  agent  should  be  withdrawn  before  the  opening  is  so  far  closed  as 
to  interfere  with  the  act.  If  the  two  outer  stitches  be  placed  too  closely 
together,  the  cord  will  be  pinched  and  the  circulation  impeded ;  if  too  far 


Fig.  1134. — Operation  for  the  radical  cure  of  inguinal  hernia,  ITalsted's  method.  Apo- 
neurosis of  external  oblique  divided  and  drawn  aside,  exposing  internal  oblique  and 
inguinal  canal.  Upper  dotted  line  shows  direction  and  extent  of  division  of  internal 
oblique  muscle.  Lower  dotted  line,  the  direction  and  extent  of  division  of  the 
coverings  of  the  sac. 


apart,  a  weakened  point  will  invite  the  recurrence  of  hernia.  "  The  precise 
point  to  which  the  cord  is  transplanted  depends  upon  the  condition  of  the 
muscles  at  the  internal  ring.  If  they  are  thick  and  firm,  and  present  broad, 
raw  surfaces,  the  cord  may  be  brought  out  here.  But  if  the  muscles  be 
attenuated  at  this  j^oint,  and  present  thin,  cut  edges,  the  cord  is  transplanted 
farther  out." 

Halsted  regards  with  especial  favor  the  employment  of  silver  wire  for 
suturing,  not  only  because  of  permanency,  but  also  on  account  of  the  influ- 
ence on  germs  of  the  chemic  changes  incident  to  association  with  living 
tissues. 


OPERATIONS  OX   VISCERA  CONNECTED  WITH    PERITONAEUM.    921 

llic  licsuUs. — In  195  cases  5.G  per  cent  relupscd  in  from  six  months  to 
nine  years.  With  primary  union  3.3  per  cent  rehipsed  ;  witli  secondary, 
25  per  cent.  There  seems  to  be  no  doubt  tliat  occasional  atroi)hy  of  the  tes- 
ticle follows  this  method  of  j)ractice.  The  following  communication  of 
April  28, 1900,  from  Dr.  Ilalsted  to  us  is  expressive  of  its  own  significance  : 

"  We  still  employ  silver  wire,  and  find  the  subcutaneous  suture  as  iiighly 
important  as  ever.  The  essential  points  seem  to  be  tiie  following  :  In  over 
109  cases  in  wliich  we  have  excised  the  veins  of  the  cord,  there  has  not  been 
a  single  recurrence  at  the  site  of  the  transplanted  cord.  The  atrophy  of  the 
testicle,  which  occasionally  accompanied  excision  of  the  veins,  we  now  no 
longer  fear,  because  we  employ  great  caution  in  excising  these  veins.  We 
do  it  with  a  sharp  knife,  making  very  careful  dissection  so  as  to  injure  no 


\ 


Fig.  1135.— Operation  for  the  radical  cure  of  inguinal  hernia.  Halsted's  method.  The 
internal  oblique  muscles  and  coverings  of  sac  have  been  divided.  The  sac.  veins,  and 
vas  deferens  drawn  out  preparatory  to  excision  of  sac ;  ligature  and  excision  of  the 
veins. 


blood-vessels.  As  a  rule,  I  do  not  transplant  the  vas  deferens,  but  we  are 
still,  in  the  majority  of  cases,  splitting  the  internal  oblique  muscle  and  lin- 
ing the  wound  with  it.  Bloodgood  discovered  that  we  had  a  certain  per- 
centage of  recurrences  in  the  lower  angle  of  the  wound,  and  devised  an 


922 


OPERATIVE  SURGERY. 


openitiou  to  remed}'  this.  I  know  of  but  two  recurrences  since  we  liave  been 
using  the  present  method  :  one  in  the  case  of  a  very  old  man  with  a  very 
large  double  hernia,  operated  on  both  sides  with  cocain  ;  and  the  other,  in 


Fig.  1136. — Operation  for  the  nulical  cure  of  inguinal  hernia,  TTalsted's  metliod.  The 
excision  of  veins  in  hernia  and  in  varicocele.  The  vas  deferens  and  its  immediate 
vessels  and  the  niesocord  not  disturbed. 


which  there  is  a  slight  weakness  in  the  scar,  caused,  we  think,  perhaps, 
by  the  breaking  of  a  stitch  at  this  point.  It  is  only  in  a  small  propor- 
tion of  cases  that  we  find  it  necessary  to  transplant  a  portion  of  the  rectus 
muscle." 

Bloodgood^s   Modification. — Bloodgood,  noting   the   occasional    defective 
state  of  the  conjoined  tendon  due  to  either  acquired  or  congenital  causes, 


OPERATIONS   OX  VISCERA   CONNECTED   WTI'll    IMMIITON.EUM.     923 

sought  to  strengthen  tluit  part  of  the  iinatoiny  by  tnin.sphmtalion  of  a 
portion  of  the  rectus  muscle,  wliich  is  clone  in  the  following  manner: 
Before  insei'ting  the  deep  sutures  for  closure  of  the  canal  draw  upward  and 
inward  the  aponeurosis  of  the  external  and  internal  oblique  muscles,  thus 
exposing  the  sheath  of  the  rectus  muscle ;  divide  the  sheath  at  the  outer 
border  of  the  muscle  from  below  upward  for  about  two  inches;  pass  through 
the  bulging  border  of  the  muscle  two  or  three  large  black  silk  traction 
sutures,  and  draw  the  border  outward  and  downward  (Fig.  1141) ;  pass  the 
deep  sutures  of  silver  wire  (Fig.  1142)  the  same  as  before  (in  llalsted's 
method),  so  that  they  will  include  in  proper  order  the  sheath  and  fibers  of 
the  rectus  along   with  the  other  tissues;  tie  the  sutures,  thus  uniting  to 


Fig.  113T.— Operation  for  the  radical  cure  of  inguinal  hernia,  Halsted's  method.  Veins 
Jiiiatured  and  resected.  Mesocord  torn  only  at  its  center.  Silver  sutures  inserted, 
one  above  and  four  below  the  cord. 

Poupart's  ligament  the  border  of  the  rectus  from  the  symphysis  to  a  point 
corresponding  to  the  outer  limit  of  the  transplanted  cord  (Fig.  1143). 


924 


OPERATIVE   SURGERY. 


Hie  Remarks. — This  modification,  while  originally  supplementary  to 
Ilalsted's  method,  can  be  applied  to  others  in  which  the  canal  is  freely 
laid  open. 

The  Results. — In  30  cases  thus  far  reported  not  a  relapse  has  taken  place. 
There  now  appears  to  be  no  reasonable  doubt  of  the  fact  that  this  expedient 


-r—  APON.Or 

r^  I"      H  EXTERN. OBL. 


Fig.  11.38. — Operation  for  the  radical  cure  of  inguinal  hernia,  Halsted's  method.  Outer 
two  tliirds  made  secure  by  transplantation  and  approximation  of  muscular  borders. 
If  conjoined  tendon  be  narrow  or  frail  the  inner  third  is  protected  by  transplantation 
of  borders  of  the  rectus  abdominis. 


can  be  safely  utilized  and  confidently  trusted.     Slajmer  reports  12  per  cent 
relapses  within  six  months  to  five  years  (Wolfer). 

Lucas-Championniere's  Method  {Inguinal  Hernia). — Make  an  incision 
three  or  four  inches  in  length  parallel  with  and  half  au  inch  above  Poupart's 
ligament  into  the  inguinal  canal ;  separate  the  sac  from  the  cord,  and  liga- 
ture the  sac  well  above  the  neck,  leaving  the  cord  lying  in  the  canal ;  close 
the  canal  with  a  series  of  mattress  sutures  placed  in  such  a  manner  as  to 
cause  the  muscles  at  the  upper  border  of  the  canal  to  overlap  the  lower 
border.  Jl,  5,  c,  d  indicate  the  musculo-aponeurotic  upper  flap  ;  e,  /,  g,  h 
the  aponeurotic  lower  flap ;  i,  2,  S,  4  indicate  catgut  sutures  inserted  first, 
and  at  the  edge  of  the  lower  flap.  The  ends  of  tliese  sutures  are  passed 
under  and  well  up  and  through  the  upper  flap  and  tied,  thus  bringing  border 


orEUATlUNS   U\    VISCKKA   CONNECTED   WITH    J'ERITUN.EUM.     925 


e,  f  of  the  lower  ihip  to  the  dotted  line  f,  /,  as  noted  in  Fig.  1144.  The 
border  r,  (/  of  tiie  iii)])cr  Ihip  is  brouglit  down  by  similar  sutures  and  fastened 
to  Poupart's  ligament,  c,  d. 

The  liesults. — Championniere  himself  reports  that  of  050  cases  but  4 
died  from  the  operation,  and,  as  far  as  could  be  ascertained,  22  relapses 
had  occurred. 

Kocher's  Method  {Inguinal  Hernia). — Make  an  incision  a  finger's  breadth 
above,  parallel  with,  and  corresponding  to  the  inner  two  thirds  of  Poupart's 
ligament,  down  to  the  aponeurosis  of  the  external  oblique ;  expose  the  apo- 
neurosis along  the  line  of  incision  ;  expose  the  hernial  sac  at  the  external 
ring  (Fig.  1145)  by  extension  downward  of  the  primary  incision,  and  careful 
division  of  the  several  tissues  lying  above  it;  isolate  the  sac  at  this  situation 
in  the  usual  manner  from  the  structures  of  the  cord,  and  carefully  se2)arate 


Fig.  1139.  Fig.  1140. 

Fig.  1139.— Operation  for  the  radical  cure  of  inguinal  hernia,  Ilalsted's  method.  Apo- 
neurosis of  external  oblique  closed  In'  silver-wire  mattress  sutures,  ends  bent  down 
and  buried. 

Fig.  1140.— Operation  for  the  radical  cure  of  inguinal  hernia,  Halsted's  method.  The 
introduction  of  the  subcuticuhir  continuous  wire  suture.  Tlie  suture  is  carefully 
withdrawn  after  suitable  union  is  secured. 

and  withdraw  it  from  the  scrotum  (Fig.  114G) ;  separate  the  sac  from  the 
tissues  above  while  drawing  downward  firmly  upon  it,  until  the  part  of  the 
sac  that  occupied  the  internal  abdominal  ring  is  exposed  ;  reduce  and  retain 
in  position  the  contents  of  the  sac  ;  transfix  the  upper  limit  of  the  sac  with  a 
needle  armed  with  a  strong  silk  ligature  and  tie  in  halves ;  make  a  small  open- 


926 


OPERATIVE  SURGERY. 


ing  tlirough  the  aponeurosis  above  and  external  to  Poupart's  ligament  (Fig. 
1145) ;  introduce  through  the  opening  («)  and  push  along  the  under  surface  of 


Fio.  1141. — Operation  foi  tin  i.tdiul  cure  of  infrninal  hpriii.i.  ISliHidfjood's  inodification 
of  Halsled's  method.  S,ic  o\ti'-od  and  poritonoal  cavity  closed  ;  internal  oblique  mus- 
cle divided,  rectus  exposed  and  transplanted  inward,  ready  for  deep  sutures,  a,  a. 
Traction  loops  applied  to  divided  borders  of  the  internal  oblique  muscle,  b,  h.  Trac- 
tion loops  applied  to  borders  of  aponeurosis  of  external  oblique  muscle,  c.  Cord 
raised  permitting  passage  of  the  border  of  the  rectus. 

the  aponeurosis,  through  the  external  abdominal  ring,  a  long,  curved  dressing 
forceps  (Fig.  1146) ;  seize  the  fundus  of  the  sac  with  the  forceps  and  with- 
draw it,  dragging  the  sac  upward  through  the  opening  (Fig.  1147) ;  draw 
upward  and  outward  on  the  sac  away  from  the  cord,  pulling  the  neck  of  the 
sac  well  into  the  aponeurotic  incision ;  transfix  and  sew  the  neck  of  the  sac 
to  the  abdominal  wall ;  turn  the  sac  downward  on  the  aponeurosis  along  the 
course  of  the  inguinal  canal ;  introduce  the  finger  into  the  canal  to  protect 


Oi'EKATlUNS   ON    \iSCKliA   CONNECTED   WITH    i'EJilToN.EL'.M.     <)27 

the  cord,  while  severul  sutures  are  passed  as  deeply  as  possible  through  the 
aponeurosis  and  sac  in  the  manner  shown  (Fig.  1148),  and  tied  firmly;  cut 
away  the  remainder  of  the  sac,  and  pass  a  deep  suture  through  the  borders  of 
the  internal  ring  close  to  and  beneath  the  neck  of  the  sac ;  finally,  so  pass 
several  sutures  tlirough  the  lower  fibers  of  the  internal  oblique  and  trans- 
versalis  muscles  as  to  narrow  the  inguinal  canal  and  fortify  it  in  front  when 
tied. 

The  Modification. — Carry  the  sac  outward  and  u[)ward — instead  of  down- 
ward on  the  aponeurosis — toward  the  anterior  iliac  spine,  and  sew  it  to  the 


ATTACHMENT  OF  RECTUS/ 
TO  SYM.PUB. 

SPINE  PUB. 


Fig.  1142. — Operation  for  the  radical  cure  of  inguinal  hernia,  Bloodgood's  modification 
of  rialsted's  method.  Cord  removed  so  as  not  to  obscure  demonstration.  «,  a. 
Divided  borders  of  internal  oblique  muscle,     b,  h.'  Ends  of  resected  cord. 

aponeurosis  of  the  external  oblique,  and  thus  draw  the  peritonaeum  still 
further  outward,  and  make  it  impossible  for  a  hernia  to  escape  along  the 
course  of  the  cord  (Kocher). 


928 


OPERATIVE  SURGERY. 


The  Eemarks. — This  method  is  applicable  to  those  cases  in  which  the 
sac  is  not  too  large  nor  too  thick  to  lead  to  impairment  of  the  strength  of 
the  anterior  wall  of  the  canal.     In  the  instances  of  incomplete  hernia  it  is 


Fig.  1143. — Operation  for  the  radical  cure  of  inguinal  hernia,  Bloodgood's  modification 
of  Halsted's  method.  The  transplanted  border  of  the  rectus  united  to  Poupart's 
ligament,  showing  slight  change  in  the  direction  of  its  fibers. 

better  to  employ  another  method  of  practice.  Dnring  the  passage  of  the 
final  sutnres  directed  to  narrowing  the  canal  careful  attention  is  necessary 
to  avoid  puncture  and  perhaps  inclusion  of  the  cord. 

The  Results. — In  111  operations  no  death  ensued  ;  recurrence  hap- 
pened in  3.6  per  cent  of  the  cases  within  from  six  months  to  two  years 
and  upward. 

Macewen's  Method  {Inguinal  Hernia). — Maceiven's  operation  for  radical 
cure  of  hernia  is  one  of  the  best  of  the  earlier  methods  practiced,  and  before 
the  advent  of  the  more  modern  methods  it  was  regarded  more  highly  in  this 
country  than  any  other  plan  of  procedure.  After  exposure  of  the  inguinal 
canal  and  internal  ring  the  operation  is  divided  into  two  steps :  1,  the 
formation  of  an  abdominal  serous  pad ;  2,  the  closure  of  the  inguinal  canal. 
The  following  description  is  in  Macewen's  own  language  : 

"A.  The  Formation  of  a  Pad  on  the  Abdominal  Surface  of  the  Circum- 
ference of  the  Internal  Ring. — 1.  Free  and  elevate  the  distal  extremity  of 
the  sac,  preserving  along  with  it  any  adipose  tissue  that  may  be  adherent  to 


Ol'KKATlONS   ON    VISCKKA   ('oNNErTI«;i)    WITH    I'KIIl'J'oN JOUM.     929 


it;  when  this  is  done,  ])ull  down  the  sac,  and,  vvliilc  maintaining  tension 
upon  it,  introduce  the  index  finger  into  tlie  inguinal  canal  (Fig.  1140),  sepa- 
rating the  sac  from  the  cord  and  from  the  parietes  of  the  canal. 

"2.  Insert  the  index  finger  outside  the  sac  until  it  readies  the  internal 
ring ;  there  separate  with  its  tip  the  peritonaeum  for  about  half  an  inch 
round  the  wliole  abdominal  aspect  of  the  circumference  of  the  ring. 

"3.  A  stitch  is  secured  firmly  to  the  distal  extremity  of  the  sac.  The 
end  of  the  thread  is  then  passed  in  a  proximal  direction  several  times 
through  the  sac,  so  that,  when  })ulled  upon,  the  sac  becomes  folded  u})()n 
itself,  like  a  curtain  (Fig.  1150). 

"  The  free  end  of  this  stitch,  threaded  on  a  hernia  needle,  is  introduced 
through  the  canal  to  the  abdominal  aspect  of  the  fascia  transversalis,  and 
there  penetrates  the  anterior  abdominal  wall  about  an  inch  above  the  upper 
border  of  the  internal  ring.  The  wound  in  the  skin  is  pulled  upward,  so  as 
to  allow  the  point  of  the  needle  to  project  through  the  abdominal  muscles 
without  penetrating  the  skin  (Fig.  1151). 

"  The  thread  is  relieved  from  the  extremity  of  the  needle  when  the  latter 
is  withdrawn.  The  thread  is  pulled  through  the  abdominal  wall ;  and,  when 
traction  is  made  upon  it,  the  sac, 
wrinkling  upon  itself,  is  thrown 
into  a  series  of  folds,  its  distal  ex- 
tremity being  drawn  fartliest  back- 
ward and  upward.  An  assistant 
maintains  traction  upon  the  stitch 
until  the  introduction  of  the  su- 
tures into  the  inguinal  canal;  and, 
when  this  is  completed,  the  end  of 
the  stitch  is  secured  by  introducing 
its  free  extremity  several  times 
through  the  superficial  layers  of  the 
external  oblique  muscles.  A  pad 
of  peritonaeum  is  thus  placed  upon 
the  abdominal  side  of  the  internal 
opening,  where,  owing  to  the  ab- 
dominal aspect  of  the  circumfer- 
ence of  the  internal  ring  having 
been  refreshed,  new  adhesions  may 
form. 


"  B.  Closure 
Canal. — The  sac 
turned   into   the 


of  the  Inguinal 
having  been  re- 
abdomen  and  se- 


FiG.  1144. — Operation  for  the  radical  cure  of 
inguinal  hernia,  Lucas-Chanipionniere's 
method. 


cured  to  the  abdominal  circumfer- 
ence of  the  ring,   this   aperture   is 
closed  in  front  of  it  in  the  follow- 
ing manner:   The  finger  is  introduced  into  tlie  canal,  and  lies  between  the 
inner  and  lower  borders  of  the  internal  ring,  in  front  of  and  above  the  cord. 
It  makes  out  the  position  of  the  epigastric  artery  so  as  to  avoid  it.     The 


930 


OPERATIVE   SURGERY. 


single 


RS 


^ 


> 


threaded  hernia  needle  is  then  introduced,  and,  guided  by  the  index  finger, 
is  made  to  penetrate  the  conjoined  tendon  in  two  places  (Fig.  ll'ri) :  First, 
from  without  inward,  near  the  lower  border  of  the  conjoint  tendon  ;  sec- 
ondly, from  within  outward,  as  high  up  as  possible  on 
^  the  inner  aspects  of  the  canal.      This  double   pene- 

^~  tration  of  the  conjoint  tendon  is  accomplished  by  a 

crewlike  turn  of  the  instrument.     One  sin- 
gle thread  is  then  withdrawn  from  the 
j)oint  of  the  needle  by  the  index 
finger,  and,  when  this  is  ac- 
complished, the  needle,  along 
with  the  other  extremity  of 
the  thread,  is  removed.     The 
conjoint  tendon  is  therefore 
penetrated     twice     by    this 
thread,  and  a  loop  left  on  its 
abdominal  aspect  (Fig.  1153). 
>  "  The  other  hernia  needle, 

threaded  with  that  portion 
of  the  stitch  which  comes 
from  the  lower  border  of  the 
conjoint  tendon,  guided  by 
the  index  finger  in  the  in- 
guinal canal,  is  introduced 
from  within  outward,  through 
Poupart's  ligament,  which  it 
penetrates  at  a  point  on  a 
level  with  the  lower  stitch  in 
the  conjoint  tendon  (Fig. 
115-1).  The  needle  is  then 
completely  freed  from  the 
thread  and  withdrawn. 

"  The  needle  is  now 
threaded  with  that  portion 
of  the  catgut  which  protrudes 
from  the  upper  border  of  the 
conjoint  tendon,  and  is  introduced  from  within  outward  through  the  trans- 
versalis  and  internal  oblique  muscles,  and  the  aponeurosis  of  the  external 
oblique  at  a  level  corresponding  with  that  of  tlie  upper  stitch  in  the  conjoint 
tendon.  It  is  then  quite  freed  from  the  thread  and  withdrawn  (Fig.  1155). 
"  There  are  now  two  free  ends  of  the  suture  on  the  outer  surface  of  the 
external  oblique,  and  these  are  continuous  with  the  loop  on  the  abdominal 
aspect  of  the  conjoint  tendon  (Fig.  1155).  To  complete  the  suture  the  two 
free  ends  are  drawn  tightly  together  and  tied  in  a  reef  knot.  This  unites 
firmly  the  internal  ring. 

"  The  same  stitch  may  be   repeated  lower  down  the    canal   if    thought 
desirable.     In  adults  it  may  be  well  to  do  so  when  the  gap  in  the  abdominal 


Fig. 


1145. — Operation  for  the  radical  cure  of  inguinal 
hernia.  Kocher's  method.  Exposure  of  the  apo- 
neurosis of  the  external  oblique  muscle,  of  the 
external  abdominal  ring,  and  the  cord.  Short, 
transverse  incision  (a)  opening  for  introduction  of 
forceps. 


OPKKATIOXS   ON    VISCKRA    COXNHCTKI)    WITH    I'lMflTONMCL'M.     \K]\ 


parietes  is  wide.     The  jiillars  of  the  exteiiuil  ring  iiuiy  likewise  be  brouglit 
together. 

"In  order  to  avoid  comjiression  of  tlie  cord,  it  ought  to  be  examined 
before  tightening  each  stitch.  The  cord  ought  to  lie  behind  and  below  the 
sutures,  and  be  freely  movable  in  the  canal.  It  is  advisable  to  introduce  all 
the  necessary  sutures  before  tightening  any  of  them.  When  this  is  done, 
they  might  be  all  experimentally  drawn  tight,  and  maintained  so  while  the 
operator's  linger  is  introduced  into  the  canal  to  ascertain  the  result.  If 
satisfactory,  they  are  then  tied,  beginning  with  the  one  at  the  internal  ring, 
and  taking  up  in  order  any  others  which  may  have  been  introduced.  In  the 
great  majority  of  cases  the  stitch  in  the  internal  ring  is  all  that  is  required. 
"  During  the  operation  the  skin  is  retracted  from  side  to  side,  to  bring 
the  parts  into  view  and  to  enable  the  stitches  to  be  fixed  subcutaneously. 
A\  lieu  tlie  retraction  is  relieved,  the  skin  falls  into  its 
normal  position,  the  wound  being  ojiposite  the  external 
ring.  The  operation  is  therefore  partly  subcutaneous." 
77ie  Results. — Macewen's  personal  experience  in 
his  own  method  shows  2  deaths  in  1G4  cases;  107  were 
traced  with  5  relapses ;  93  cases  were  cured  at  the 
end  of  from  two  to  ten  years. 

Deaver,  after  opening  the  inguinal 
canal  through  the  usual  free  inci- 
sion, exposes  and  separates 
the  hernial  sac  the  entire 
length,  makes  a  small  open- 
ing into  it,  frees  the  sac  of 
adhesions    within,  reduces 
the  contents   into  the  ab- 
dominal cavity,   folds    the 
sac   upon  itself,  carries  it 
into  position   beneath  the 
peritongeum,  placing  it  at 
the  site  of  the  internal  ab- 
dominal ring,  and  fastens 
it  there  by  sutures  to  the 
abdominal  wall.     He  then 
closes  the  canal  from  with- 
in outward  by  means  of  in- 
terrupted   (not    mattress) 
silver    sutures   introduced 
r.i.lical  cure  of  in<;uinal   substantially  into  the  tis- 
Sac  separated  and  end   sues,  after  the  manner  of 
Halsted.      This   modifica- 
tion  adds   to   the  Bassini 
and  Halsted  methods  the  subperitoneal  pad  of  Macewen.     Since  only  theo- 
retical claims  appear  as  yet,  the  assumed  advantages  of  the  proposition  await 
practical  demonstration. 
65 


Fig.  1146.— Operation  for   the 
hernia.  Kocher's  method, 
seized  by  forceps  passed  through  the  transverse  inci 
sion  (a)  down  the  inguinal  canal. 


932 


OPERATIVE   SURGERY. 


Fowler  presents  a  modification  which,  while  adding  to  the  dangers  of 
operation,  certainly  appears  to  oiler  increased  advantages ;  but  whether  or  not 
these  qualities  are  mutually  commensurate  experience  only  can  determine. 

The  purpose  of  the  opera- 
tion is  to  obliterate  the  in- 
ternal ring,  which  is  accom- 
plished as  follows:  Expose 
the  inguinal  canal  out  to 
the  internal  ring  by  divi- 
sion of  the  overlying  struc- 
tures ;  isolate  the  cord  and 
sac  from  the  surrounding 
tissues  and  from  each  other 
to  the  internal  ring;  open 
the  sac  and  reduce  the  con- 
tents; cut  off  the  sac  at  the 
neck,  grasping  the  divided 
borders  with  forceps ;  draw 
the  cord  out  of  the  way ; 
locate,  isolate,  and  divide 
the  deep  epigastric  vessels 
between  two  ligatures ;  in- 
troduce the  index  finger 
through  the  opening  at  the 
neck  of  the  sac  into  the  peri- 
toneal cavity  and  carry  it 
along  the  posterior  wall  of 
the  canal ;  press  the  finger 
forward  to  make  the  tissues 
tense  and  divide  them  from 
without  inward  on  the  fin- 
ger ;  place  the  cord  within 
the  peritoneal  cavity,  while 
carefully  preventing  the  es- 
cape of  intestines;  beginning  outside  of  the  internal  ring,  approximate 
broadly  the  serous  surfaces  along  the  divided  borders  and  unite  them  with 
each  other  by  through-and-through  sutures  passed  from  side  to  side ;  close 
and  obliterate  the  inguinal  canal,  and  unite  the  borders  of  the  external 
wound  respectively  with  absorbable  sutures. 

The  Remarks. — Fowler  suggests  in  those  instances  in  which  the  internal 
ring  is  greatly  enlarged  in  all  directions,  a  slit  be  made  at  the  lower  border, 
so  that  the  cord  will  enter  more  readily  the  abdominal  cavity.  During  the 
sewing  of  the  periton;¥um  and  the  superimposed  fascia,  any  previous  undue 
relaxation  of  these  tissues  can  be  remedied.  The  inner  angle  of  the  wound 
should  be  low  enough  to  cause  slight  curving  of  the  cord  upward  and  for- 
ward as  it  passes  out,  permitting  it,  however,  to  escape  unconstricted  because 
of  change  in  direction  or  sewing. 


Fig.  1147. — Operation  for  the  radical  cure  of  inguinal 
hernia,  Kocher's  method.  Sac  drawn  out  through 
short  transverse  incision.  Transfixion  of  upper 
limit  of  sac  with  silk  ligature. 


OI'KUATIONS   ON    VISCERA   CONNECTED    WI'I'H    PEKITON.EL'M.     933 


Other  Methods  of  Practice. — The  methods  of  liall,  Banks,  Barker,  Ben- 
nett, and  others  have  each  contributed  much  indeed  to  the  final  outcome  of 
relief,  and  each  would  receive  extended  mention  if  circumstances  required 
and  time  and  opportunity  approved. 

The  General  Frecaations. — The  vas  deferens  should  be  carefully  pre- 
served from  injury  for  obvious  reasons.  The  separation  of  the  sac  from  the 
structures  of  the  cord  should  be  cautiously  practiced  to  avoid  unnecessary 
mutilation  and  subsequent  necrosis  of  the  tissues.  It  is  often  wiser  to  sepa- 
rate the  sac  from  the  cord  by  tearing  at  the  points  of  great  adhesion  than  to 
endeavor  to  separate  the  structures.  In  tying  the  neck  of  the  sac,  transfixion 
should  be  practiced  in  order  to  keep  the  ligature  in  proper  place  after  the 
sac  is  cut  away  and  intra-abdominal  pressure  is  brought  to  bear  upon  it. 
Mattress  sutures  meet  the 
same  indication.      Careful         ^^~ 

inspection  of  the  interior  ^.^ 

of  the  sac  should  be  jirac-      /  )  "^ 

tieed  before  ligaturing  to      i  ^    \ 

note  if  it  be  free  of  ab- 
dominal contents.  Twist- 
ing of  the  sac ;  passing  the 
fingers  and  thumb  from 
above  dow^nward  on  the 
outside  ;  introduction  of 
the  finger  to  press  back  the 
contents,  and  tying  of  _ 
the  sac  across  the  end  _ 
of  the  finger  as  it  is 
withdrawn  are  each  good 
methods  of  practice  to  pre- 
vent the  inclusion  of  un- 
welcome contents.  Prompt 
and  uninterrupted  union 
are  the  great  desiderata  of 
success,  therefore  irritating 
sutures,  oozing,  and  granu- 
lating surfaces  should  be 
eschewed.  Haemorrhage 
from  faulty  tying  of  the 
omentum  has  been  known 
to  cause  death,  hence  the 
omental  stump  should  be 
tied  in  small  sections  (Figs. 
1107   and    1108)   and   not 

returned  until  after  the  arrest  of  oozing  is  assured.  Injury  of  the  sper- 
matic and  epigastric  arteries  may  give  rise  to  severe  and  even  fatal  haemor- 
rhage. Ligature  of  the  omentum  may  be  followed  by  perforation  of  the 
bowel  if  tied  too  close  to  that  organ.     Suppuration  of  the  omental  stump 


I 


Fig.  1148.— Operation  for  the  radical  cure  of  inguinal 
hernia.  Kocher's  method.  Sac  drawn  downward  on 
aponeurosis  and  sewed  in  place. 


934 


OPERATIVE  SURGERY. 


Fig.  1149. — Operation  for  the  cure  of  inguinal 
hernia,  Macewen's  method.  Separating 
the  sac  from  the  cord  and  walls  of  the 
canal;  folded  sac  lying  behind  the  finger. 


Fig.  1151. — Operation  for  the  radical  euro  of 
inguinal  liernia,  Macewen's  method.  Car- 
rying the  suture  of  the  sac  from  behind 
forward  through  the  abdoTninal  muscles, 
at  a  point  aljout  an  inch  above  the  inter- 
nal ring. 


and  injury  of  tlio  bladder  wlien  in 
the  sac  (Curtis  and  Clibson)  are 
among  the  complicating  features  of 
the  operation.       In  tlie  female  the 


Fig.  1150. — Operation  for  the  radical  cure 
of  inguinal  hernia,  Macewen's  metli- 
od.  The  pad  formed  by  transfixion 
of  the  sac. 


round  ligament  should  be  carefully 
avoided. 

The  General  Remarks.  —  Xon- 
absorbable  sutures  are  regarded  by 
Bull  and  Coley,  who  have  had  a 
large  experience  and  an  unusual  op- 
portunity of  observing  the  results 
of  the  work  of  others,  as  inferior  to 
the  absorbable.  Silk,  silkworm  gut, 
and  silver  wire  esjjecially  belong  to 
the  former  class,  chromicized  cat- 
gut and  chromicized  kangaroo  ten- 
don to  the  latter.  With  this  dis- 
crimination we  are  disposed  to  agree. 
The  fact  that  delayed  and  faulty 
union  adds  ten  to  twenty  per  cent 
to  the  list  of  failures  should  lead 
the  operator  to  faithfully  eliminate 
their  causes. 

The  writer  finds  much  advantage 
is  gained  by  opening  the  sac  early 
in  the  course  of  dissection  near  to 
the  upper  end,  sufficiently  to  admit 
the  index  finger,  which  serves  admi- 
rably as  a  guide  and  support  during 
the  complete  separation. 

The  After-treatment. — A  strip 
of  iodoform  gauze  placed  upon 
closed  borders  of  the  wound  sur- 
mounted   with    dry   aseptic    gauze 


OI'HKATloXS   OX    VISCKliA   COXXKCTKI)   WITH    I'KlilTuNyEUM.     935 


Fiu.  1152. 


Fig.  1153. 


Fir..   ]15'2. — Operation    for  the  radical  cure   of   inguinal  hernia,  Macewen's   operation. 

Needle  passing  tlirough  conjoined  tendon. 

Fig.  115:3. — Operation  for  the   radical  cure   of   inguinal    hernia,  ^Macewen's   operation. 

Ligature  carried  through  the  conjoined  tendon  in  two  places. 


Fi(i.  1154. 


Fig.  1154. — Operation  for  the  radical  cure  of  inguinal  hernia.  Macewen's  operation.     The 

lower  extremity  of  the  ligature  being  carried  through  Poupart's  ligament. 

Fig.  1155. — Operation  for  the  radical  cure  of  inguinal  hernia.     The  upper  extremity  of 

the  ligature  passed  through  Poupart's  ligament  and  the  ends  ready  for  tying. 


936 


OPERATIVE  SUllGEIiY. 


firnily  tied  in  place  with  a  spica  meets  the  usual  demands  of  the  dressing, 
lu  the  instance  of  children  a  plaster-of- Paris  s})ica  aids  in  securing  quiet  and 
uuiform  pressure.  If  the  inner  aspect  of  the  splints  be  painted  with  a  solu- 
tion of  shellac  the  discharges  will  not  soil  the  dressing,  llubber  tissue  may 
be  used  instead.  The  patient  is  kept  in  bed  for  two  or  three  weeks  after 
operation,  or  until  firm  union  has  taken  place.  The  abdominal  su])port  of 
the  dressings  is  quite  sufficient  for  this  period  of  treatment.  After  recovery 
artificial  support  by  means  of  a  bandage  or  truss  is  rarely  j)racticed  except 
in  those  cases  presenting  special  indications  for  their  use.  The  avoidance  of 
severe  physical  eft'ort  for  some  months,  however,  is  strongly  urged. 

The  liesuUs. — Operations  in  childhood  and  youth  are  followed  by  the 
best  results.  Patients  under  four  and  above  fifty  years  of  age  should  be 
approached  with  care  in  this  respect,  and  only  in  the  presence  of  special 
demands  for  the  operation.  In  selected  cases  and  with  skilled  o^ierators  the 
death  rate  is  scarcely  above  one  per  cent.  In  children  it  is  even  less  than 
this.  The  final  outcome  is  difficult  to  establish,  since  many  of  the  cases  are 
lost  to  the  observation  of  the  operator.  However,  from  GO  to  90  per  cent 
remain  cured  for  a  number  of  years — ten  and  more.  Relapses  in  64.5  percent 
of  the  cases  occur  within  six  months  after  the  operation ;  80  per  cent  during 
the  first  year  and  30  per  cent  after  that  time.  In  71  per  cent  of  the  relapses 
the  patients  were  above  thirty  years  of  age  and  under  thirty  in  29  per  cent 

(Coley).  Coley  collected  10,- 
500  cases  operated  upon  since 
1890  with  a  general  death 
rate  of  0.9  of  1  ])er  cent. 
Bassini's  method  is  per- 
formed more  often  now  than 
any  other.  As  a  rule,  a  re- 
lapsing hernia  in  this  method 
is  more  easily  controlled  than 
was  its  antecedent,  except  in 
the  instance  of  the  repair  by 
graiiuhitioii. 

Femoral  Hernia— />V;.ss7:- 
nVs  Method  for  lixtdicnl  Cure. 
— Make  an  incision  over  the 
tumor  parallel  with  and  half 
an  inch  below  Poupart's  liga- 
ment down  upon  the  sac ; 
isolate  the  sac  from  the  sur- 
rounding tissues  and  from 
the  femoral  canal  (Fig.  115G) 
as  high  up  as  possible ;  ex- 
amine and  reduce  the  con- 
tents of  the  sac  and  draw  it 
forcibly  downward  ;  transfix  the  neck  of  the  sac,  and  tie  it  in  halves  with  a 
strong  silk  ligature  ;   cut  olf  the  sac  close  to  the  ligature  and  permit  the 


Fig. 


1156. — Oporation  for  tho  radical  cure  of  femoral 
licriiia,  Bassini's  method,  a.  Falciform  process. 
b.  Pubic  portion  of  fascia  lata.  c.  Poupart's  lig- 
ament. 


Ul'KRATlOxNS   UN    VISCERA   C'0N'NE("TE1)    WITH    rElllTON.EUM.     937 


stump  to  disappear  upward  to  the  abdominal  cavity ;  unite  I'oupart's  liga- 
ment and  the  falciform  process,  at  the  outer  side  with  the  pectineal  fascia 
and  at  the  inner  with  the  pubic  portion  of  the  fascia  lata,  with  five  or  six 
silk  sutures  carried  through  the  respective  borders  of  these  tissues  and  tied 
(Fig.  1150).  The  cutaneous 
incision  is  closed  in  the  usual 
manner  without  drainage. 

IVie  Comments. — The  u])])er 
first  three  stitches  unite  1V)U- 
part's  ligament  with  the  pectin- 
eal fascia  ;  the  second  three 
the  pubic  portion  of  the  fascia 
lata  with  the  falciform  process 
of  the  iliac  portion,  thus  closing 
the  lower  end  of  the  femoral 
canal  by  apposition  of  its  ante- 
rior and  posterior  borders. 

Coley  closes  the  canal  by 
means  of  the  purse-string  su- 
ture (Fig.  Il0()  passed  in  the 
following  manner :  Carry  by 
means  of  a  curved  needle  a 
ligature  of  kangaroo  tendon 
around  and  close  to  the  wall  of 
the  canal,  passing  through  the 
inner  and  npper  part  of  Pou- 
part's   ligament,   the   pectineal 

fascia  and  superficial  fibers  of  the  pectineus  nniscle  behind  the  canal,  the 
fascia  lata  overlying  the  vessels,  and  finally  through  Poupart's  ligament 
about  a  quarter  of  an  inch  from  the  point  of  beginning.  The  sac  should 
be  completely  freed  and  the  stump  allowed  to  recede  far  upward  before  the 
ligature  is  tied.     Carefully  avoid  the  femoral  vein. 

The  Results. — Bassini  reports  54  cases  with  no  mortality,  of  which  41 
remained  cured  from  one  to  nine  years.  Coley  reports  28  cases  treated  by  the 
purse-string  method,  with  no  ascertained  relapse,  10  of  which  were  traced 
from  two  to  seven  years.  Coley  advises  Bassini's  method  of  closure  if  the 
femoral  ring  be  very  large. 

Kocher's  Method  {Femoral  Hernia,  Badical  Cure). — Make  an  incision 
along  the  inner  third  of  Poupart's  ligament  down  to  the  sac ;  isolate  the  sac 
up  to  the  crural  ring ;  expose,  isolate,  and  reduce  the  contents  of  the  sac ; 
make  a  small  opening  from  above  Poupart's  ligament  through  the  outer 
pillar  of  the  external  abdominal  ring ;  introduce  a  forceps  through  the  open- 
ing, seize  the  fundus  of  the  sac  and  draw  it  firmly  upward  through  the  slit 
in  the  pillar ;  unite  the  sac  to  the  crural  ring  by  silk  sutures  passed  deeply 
through  Poupart's  ligament,  the  deep  crural  arch,  the  sac  and  the  pectineal 
fascia ;  cut  off  the  sac  close  to  the  sutures ;  close  the  external  wound  and 
dress  in  the  usual  manner. 


Fig.  1157. — Operation  fortlie  radical  cure  of  femo- 
ral hernia.    Purse-string  suture,  Colev's  method. 


938 


OPERATIVE   SURGERY. 


same  lisfament. 


The  Comment}^. — Avoid  puncture  of  the  femoral  vein  in  sewincr,  to 
obviate  both  haemorrhage  and  thrombosis.  Gordon  closed  the  canal  in 
an  ingenious  and  effective  manner  by  two  sutures  so  placed  as  to  supple- 
ment the  closure  by  interposition  of  the  lower  fibers  of  the  internal  oblique 
and  transversalis  muscles.  Bottini  united  the  margins  of  the  crural  canal 
to  Gimbernat's  ligament ;  Loicenstein  united  the  falciform  process  to  the 
The  periosteal  flap  closures  of  Trendelenburg  and  others 

are  ingenious  conceptions,  but 
are  hardly  warranted  in  the 
presence  of  the  simpler  and 
efficient  methods  of  Bassini, 
Coley,  and  fithers. 

Umbilical  Hernia  {Radical 
Cure). — Two  methods  of  pro- 
cedure are  commended  for  the 
radical  cure  of  umbilical  her- 
nia :  1,  the  reduction  of  the 
contents  and  the  freshening  and 
suture  with  each  other  of  the 
respective  tissues,  as  in  closure 
of  abdominal  wounds  and  the 
treatment  of  ventral  hernia; 
2,  the  transposition  of  tissite 
with  the  object  of  strengthen- 
ing the  median  line.  In  the 
first  method  {Greiy  Smith)  un- 
der strict  asepsis  open  the  cu- 
taneous coverings  from  top  to 
bottom  (Fig.  1158) ;  make  a 
small  incision  at  the  thinnest 
part  into  the  sac,  cautiously 
shunning  the  bowel  (b)  ;  di- 
vide the  sac  with  scissors, 
guided  by  the  fingers,  carefully 
avoiding  the  omentum  (c) ;  re- 
turn the  bowel  into  the  cavity, 
overcoming  the  opposing  adhe- 
sions by  separation,  ligation,  or 
cutting,  as  seems  best;  intro- 
duce an  anchored  sjionge  or 
wiper  (Fig.  66)  into  the  umbil- 
ical opening  to  prevent  the  en- 


FiG.  1158. — Operation  for  the  radical  cure  of  um- 
bilical hernia.  Greig  Smith's  method.  A.  Trans- 
verse section  through  hernia,  a,  d.  Sujierflu- 
ous  skin  and  sac.  the  former  removed  on  the 
outer,  the  latter  on  the  inner  aspect  of  the  tu- 
mor, b.  Intestine,  c.  Omentum,  e.  Integu- 
ment. /.  Superficial  and  deep  fascije.  g.  3Ius- 
cles.  A.  Peritonseura.  ?"./ Incisions  upon  recti 
muscles  made  through  fascia  surrounding  ring. 
Dotted  lines  V)etween  a,  i  and  d.j  indicate  the 
course  of  separation  of  the  sac.  B.  Superflu- 
ous tissue  removed,  bowel  returned,  omentum 
and  sac  taken  away,  and  sutures  a.  d  inserted. 
i.j.  Structures  around  the  ring  opened  and  su- 
tures applied.  Other  references  same  as  in  A. 
C.  Suturing  completed.  D.  Bird's-eve  view  of 
wound,  sutures  inserted  for  tving. 


trance  of  blood  to  the  abdomen 
during  the  dissection  ;  ligature  and  divide  the  omentum  where  it  passes 
through  the  umbilicus  (?',/),  and  return  the  stump  to  the  abdomen;  remove 
the  herniated  omentum  along  with  the  sac,  without  separating  the  adhe- 
sions ;  remove  the  superfluous  integuments  and  sac  down  to  the  circumfer- 


OI'KUATIOXS   (»N'    VISCKKA    (  O.W  K(  "I'KD    Willi    J'KKI'I'ON  yKU.M.     U'.^J 


enee  of  the  opening;  strip  the  peritouii'iiin  Uom  around  the  umbilical 
opening  (/,/)  and  push  it  into  the  abdonu-n  ;  liberate  the  adjacent  borders 
of  the  recti  muscles  by  free  separation  of  the  margins  of  the  ring ;  insert 
deep  sutnrcs  through  the  structures  down  to  the  peritoniuum  as  indicated 
{(1,(1  and  /, /,  H  and  (');  remove  the  wipers  from  the  abdomen,  tie  tlie 
sutures  lirnily,  and  cut  short  tlieends;  introduce  between  the  intervals  of 
the  preceding  sutures  the  superlicial  ones  {a,  b),  and  tie  as  indicated  in  C 
The  wound  is  then  dressed  in  the  usual  manner. 

In  BoeclceVs  method  the  sac  is  isolated  and  the  umbilicus  excised  tli rough 
an  elliptical  incision  of  sufficient  dimensions  to  meet  the  demands  of  tlie 
case;  the  sac  is  opened,  intestine  restored,  and  omentum  returned  or 
removed  as  seems  essential  to  success ;  the  borders  of  the  base  of  the  sac 
are  joined  with  chain  sutures,  the  sac  is  resected,  and  the  stump  turned 
inward  ;  the  fibrous  borders  arc  freshened  even  to  the  muscular  structures  of 
the  recti,  if  need  be.  The  peritoneal,  fascial,  fibro-muscular,  and  cutaneous 
tissues  are  united  in  turn  from  below 
upward  with  silver,  kangaroo-tendon, 
or  chromicized-catgut  sutures,  the 
last  series  being  of  silkworm  gut. 


-Operation  for  the  radical  cure  of  uml)ilical  hernia.  Dauriac's  method, 
cular  ses^inents  prepared  for  transference. 
Fig.  1160. — Operation  for  the  radical  cure  of  lunbilical  hernia.  Dauriac's  inetliod. 
cular  segments  transferred  and  united,  and  sutures  laid  for  closure. 


3Ius- 
Mus- 


Tlie  method  of  transference  (Dauriac)  is  practiced  as  follows:  Expose 
the  abdominal  recti  muscles  through  an  incision  in  the  median  line ;  divide 
each  muscle  into  two  portions  by  a  downward  longitudinal  incision  placed 
nearer  to  the  inner  than  to  the  outer  borders  of  the  muscles ;  divide  the 
inner  portions  with  the  corresponding  part  of  the  sheath  transversely  at  the 
upper  ends  (Fig.  1159) ;    transfer  the  ends  and  unite  them  with  the  opposite 


940 


OPERATIVE  SURGERY. 


Fig.  1161. — Operation  for 
the  radical  cure  of 
umbilical  hernia,  Dau- 
riac's  method.  Manner 
of  uniting  transferred 
muscular  segments,  left 
side. 


divided  extremities  above  (Figs.  1160  and  1101)  and  close  the  remaining 
gaps  as  indicated  in  the  cut ;  ixnite  the  borders  of  the  wound  as  usual,  and 
apply  to  it  a  firm  compress.  Quenu  advises  the  following  method  of  prac- 
tice :  Freshen  and  unite  respectively  the  fascia  and  peritonaeum,  the  poste- 
rior lips  of  the  sheaths  of  the  recti,  the  recti  them- 
selves, the  anterior  lips  of  the  sheaths  of  the  recti, 
and  finally  the  remaining  soft  parts  with  each  other. 
Various  other  methods  of  flap  formation  are  advised. 
The  Remarks. — The  omentum  is  often  adherent 
to  the  sac  at  various  places,  requiring  that  the  direc- 
tion of  the  incision  be  changed  and  made  irregular ; 
this  is  of  no  account.  Transfixion  and  ligatiire  of 
the  pedicle  with  interlocking  silk  sutures  should  be 
practiced  to  render  the  vessels  secure.  Free  libera- 
tion and  firm  apposition  of  the  contiguous  borders 
of  the  recti  is  an  important  element  of  the  tech- 
nique. In  some  cases  a  single  row  of  sutures  may 
be  sufficient  to  properly  close  the  opening ;  a  double 
one  is  better.  Phelps's  wire-filigree  support  may  be 
introduced  in  umbilical  and  ventral  hernias,  espe- 
cially if  largely  and  insecurely  provided  against  return,  by  the  normal  tis- 
sues. A  hernia  elsewhere  similarly  conditioned  may  be  thus  treated.  The 
anatomy  of  the  infantile  and  of  the  congenital  forms  should  be  noted. 

The  Results. — The  results  from  the  independent  union  of  freshened 
borders  of  selected  tissues  are  excellent.  In  300  cases  265  cures  and  35  deaths 
are  reported,  a  mortality  rate  of  nearly  12  per  cent  (Boeckel).  Of  these, 
105  were  strangulated  and  195  non-strangulated,  with  a  death  rate  of  30.5 
and  1.95  per  cent  respectively.  Relapse  occurs  more  frequently  in  these 
than  in  radical  cure  of  inguinal  hernia.  The  results  of  the  experience  of 
Bull  and  Coley  and  of  the  writer  are  not  so  favorable  as  the  preceding 
appear  to  be,  and  the  differences  in  the  operative  technique  are  hardly  suf- 
ficient to  account  for  those  of  the  operative  results.  Sufficient  data  are  not 
at  hand  to  enable  one  to  judge  wisely  of  the  utility  of  cure  by  the  transposi- 
tion of  tissue. 

Ventral  Hernia  {Radical  Cure). — Ventral  hernia  usually  occurs  in  the 
median  line,  and  is  a  common  sequel  of  median  cceliotomy.  It  also  happens 
at  other  situations  of  the  abdomen  from  operative  practice.  Greig  Smith 
advised  the  separation  of  the  areolar  tissue  between  the  skin  and  peritonaeum 
(Fig.  1162)  by  means  of  the  finger  or  curved  scissors  inserted  through  a  small 
opening  made  along  the  main  direction  of  the  hernia.  The  superfluous  skin 
is  removed,  the  peritoneal  sac  turned  inward,  and  if  abundant  united  with  a 
continuous  suture  carried  through  the  areolar  tissue.  If  of  less  amount  it 
may  be  included  by  the  suture  closing  the  parietal  incision.  Healthy  mus- 
cular structure  is  freely  exposed  by  dissection,  and  the  borders  are  united 
by  suture  en  mnsse  as  noted  in  Fig.  1102. 

Tlie  Remarks. — The  abdomen  is  not  opened  in  this  procedure  ;  broad 
muscular  surfaces  are  apposed  and  the  inturned  sac  contributes  a  fenderlike 


()I'KI{A'ri()NS   ON    VISC'KltA   CONNKCTKD    WII'll    I'KKI'l'oN.Kl'.M.     <)41 


opposition  to  intestinal  pressure.  Muscular  tissue  should  be  brought  in 
contact  at  the  line  of  union  even  if  the  detachment  of  separate  bundles  be 
recpiired  for  the  purpose,  to  insure  firmer  union. 

llcrnid  following  Appendicitis. — This  inlliction  frequently  follows  free 
incisions  in  suppuratin<:;  cases  of  appendicitis.  In  the  earlier  history  of 
o{)erative  [)ractice  it  hapjiened  in  ten  to  fifteen  per  cent  of  the  instances. 
In  curing  the  inlliction  Coley  advises  free  excision  of  all  the  cicatricial  tis- 
sue, careful  dissection  and  exposure  of  the  iiitia-nal  and  external  oblique 
muscular  planes,  with  separate  suture  of  each  with  kangaroo  tendon. 

The  Nesulis. — The  results  of  operation  for  radical  cure  of  ventral  hernia 
are  much  less  favorable  and  the  fatality  is  greater  than  in  similar  procedures 
for  the  inguinal  and  femoral  kinds.  Up  to  1898  Bull  and  Coley  had 
operated  for  radical  cure  in  19  umbilical  and  15  ventral  hernias.  Of  the 
latter,  11  followed  lapa- 
rotomy and  4:  open- 
wound  treatment  of  sup- 
purative appendicitis. 

Lateral  central  her- 
nia is  rare,  and  makes 
its  appearance  at  Petit's 
triangle.  Of  ;i9  cases 
collected  by  Braun,  20 
were  congenital,  or  de- 
veloped spontaneously, 
and  9  had  a  history  of 
traumatism.  This  form 
has  not  yet  been  investi- 
gated sufficiently  to  en- 
able one  to  lay  a  special 
method  of  practice  for 
cure  on  relief  of  stran- 
gulation. The  general 
indications  of  treatment 
in  the  other  forms  have 
equal  force  in  this. 

Caecal  Hernia.— The  presence  of  the  entire  or  a  portion  of  the  cjecum  in 
a  hernial  sac  happens  in  about  four  per  cent  of  the  cases  of  hernia  in  the 
inguinal  region.  Rarely  indeed  it  is  that  the  caecum  is  not  partly  or  wholly 
covered  with  peritonaeum.  Caecal  hernia  happens  four  times  oftener  at  the 
right  than  the  left  inguinal  region,  and  is  five  times  more  frequent  at  the 
right  than  the  left  femoral  region.  The  presence  in  the  sac  of  the  caecum  is 
rarely  known  until  the  contents  are  exposed  by  incision.  If  covered  with 
peritonaeum,  the  csecum  is  readily  reduced  ;  but,  if  partially  or  entirely  uncov- 
ered, the  return  is  often  difficult,  owing  to  the  contact  of  non-serous  sur- 
faces; still,  patient  and  careful  manipulations  will  secure  a  return  of  the 
viscus,  after  which  the  operative  technique  is  similar  to  that  of  the  simpler 
forms  of  hernia. 


Fui 


.  1162. — Operation  for  the  radical  cure  of  ventral  hernia, 
Greig  Smith's  method.  A.  Transverse  section  of  ven- 
tral hernia,  a.  Stem  l)et\veen  dotted  lines  to  be  re- 
moved, b.  Hernial  pouch,  c.  Integument,  d.  Fascia. 
e.  Muscles.  /.  Fascia  and  {.eritona^um.  Lines  of  inci- 
sion indicated  by  dotted  lines.  B.  Redundant  stem 
removed.  iieritomVuiii  turned  in.  and  woinid  closed. 


942  OTERATIVE   SUKCJEKY. 

Hernia  of  the  Bladder. — Hernia  of  the  bladder  is  not  infrequent,  and  is 
chielly  dangerous  because  of  the  liability  of  cutting  into  it  before  recogni- 
tion. Gibson  reports  103  cases  in  which  the  bladder  was  wounded  in  67, 
and  uninjured  in  36.  The  bladder  may  be  intraperitoneal  or  extraperi- 
toneal, sometimes  both.  It  is  mistaken  for  tjie  primary  or  a  secondary  her- 
nial sac ;  for  cystic  tumor  and  fatty  accumulations.  When  its  presence  is 
suspected,  the  employment  of  a  hypodermic  needle  or  the  introduction  of  a 
sound  to  the  bladder  should  promptly  settle  the  matter.  The  return  of  the 
viscus  to  the  abdomen  is  not  especially  difficult.  The  wound  of  the  blad- 
der is  closed  and  the  patient  treated  in  other  respects  as  is  usual  in  such 
wounds  (page  1200). 

The  Results. — The  rate  of  mortality  is  about  twelve  and  a  half  per  cent 
(Gribson). 

Local  Ana3stliesia  in  Operations  on  Hernia. — The  employment  of  local 
anaesthesia  in  the  relief  of  strangulated  hernia  and  for  radical  cure,  espe- 
cially when  old  age  and  organic  infirmity  forbid  the  use  of  general  anaes- 
thesia, has  been  brought  prominently  into  view  by  CusJmig,  of  Baltimore. 
Operations,  relating  to  the  abdominal  contents,  of  even  greater  significance 
than  hernia  have  been  satisfactorily  practiced  with  local  anaesthesia.  Jnjil- 
tration  anmsthesia  with  the  second  solution  of  Schleich  (page  31)  has  proved 
satisfactory.  The  basis  of  the  utility  of  the  plan  rests  on  the  fact  that  the 
cocainization  of  the  trunks  of  sensation  nerves  renders  ansesthetic  the  field  of 
their  supply.  The  location  of  the  primary  incision  and  of  subsequent  dissec- 
tion to  the  nerve  trunks  and  their  areas  of  supply,  though  well  demonstrated 
by  the  illustration  (Fig.  1163),  should  be  carefully  studied  before  operation 
to  determine  their  comparative  relations  with  each  other.  The  importance 
of  the  detail  of  the  procedure  is  so  pronounced  that  we  beg  to  quote  in  full 
the  description  of  Gushing  : 

"  Steps  of  the  Operation. — Individuals  advanced  in  years  are  usually  kept 
in  bed  for  a  day  or  two  preliminary  to  the  operation,  to  give  an  indication 
of  their  ability  to  endure  recumbency,  and  for  the  purpose  of  training  them 
to  void  their  urine  in  this  position.  Evacuation  of  the  bladder  is  usually 
accomplished  by  the  aid  of  an  enema  if  any  postural  difficulty  is  experienced. 

"  It  has  been  the  custom  to  administer  hypodermically  a  tenth  or  an 
eighth  of  a  grain  of  morphin  three  quarters  of  an  hour  before,  and  to 
repeat  this  shortly  before  the  operation.  Ce(d  has  emphasized  the  efficiency 
of  this  morphin-cocain  combination,  and  I  have  found  it  most  satisfactory. 
The  drug  must  be  used  with  caution,  however,  since  occasionally  even  small 
doses  of  morphin  in  old  people  may  confine  the  bowels  and  lead  to  disten- 
tion, which  may  be  troublesome.  Similarly,  in  old  people  with  tardy  blad- 
ders, it  may  inhibit  the  proper  evacuation  of  the  urine,  though  we  have 
never  had  the  misfortune  to  observe  this. 

"  Patients  past  middle  age  also  are  usually  shaved  and  prepared  on  the 
operating  table  to  avoid  any  exposure  incidental  to  an  open  ward  prepara- 
tion. The  skin  in  the  line  of  proposed  incision  is  infiltrated  with  Schleich's 
cocain  solution,  and  the  incision  may  be  immediately  made  through  the 
linear  wheal   thus  produced.     It  is  common  experience  to  find   the  infil- 


(»l'KI{A'ri()NS   ().\    VISCKKA    ('(>\M;(  "I'lll)    WI'I'II    l'i:in'l"()NyT]U:\I.     <>4;> 

tnited  tissues  nioir  Viisfiihir  thiui  usual,  and  it  is  important  that  all  bleed - 
ino:  ])oiuts  bo  iniiuediately  clainijcd,  siiieo  a  dry  and  unstained  field  is  essen- 
tial to  tlie  success  of  the  dissection.  It  is  unnecessary  and  useless  to  attempt 
to  ana-sthotize  the  panniculiis.     As  .Schlrich   has  shown,  only  tissues  which 


LATERAL  CUTAN'S 
OF  12   D 


ANT.  5UPR.  SPINE 


LAT.  CUTAN  Ori.L. 


Fk;.  1163. — Operation  for  the  radical  cure  of  inguinal  liernia  under  local  anjesthesia. 
Cusliing's  method.  The  peripheral  distribution,  and  the  relation  of  the  trunks  of  the 
inguino-scrutal  nerves  to  the  main  incision.  1.  Ilio-liypogastric  nerve.  :?.  Ilio-ingui- 
nal  nerve.    3.  Genito-crural  nerve,  its  genital  (4)  and  crural  (5)  branches. 

can  be  '  oedematized  '  are  fitted  for  the  infiltration  method,  and  in  the  pan- 
nicnlus,  at  the  upper  angle,  practically  no  nerves  are  encountered.  If,  how- 
ever, throughout  its  whole  length,  this  incision  is  carried  down  to  the  apo- 
neurosis, unanaesthetized  fibers  of  the  ilio-hypogastric  will  be  encountered 
in  the  superficial  fat  at  the  lower  angle,  together  with  one  or  two  large  veins, 
division  of  which  is  painful,  so  that  anesthetization  of  the  panniculus  layer 
is  here  necessary,  or  else,  as  has  been  done  on  several  occasions,  the  incision 
only  at  the  upper  angle  may  be  carried  down  to  the  aponeurosis,  which  is  then 
opened  in  the  line  of  fibers  from  the  external  ring,  and  the  ilio-hypogastric 


944 


OPERATIVE   SURGERY 


and  inguinal  nerves  immediately  cocainized  with  a  one-per-cent  solution  as 
they  lie  under  it.  After  this  procedure  the  lower  angle  of  the  incision  may 
be  painlessly  carried  down  to  the  external  ring,  and  the  remaining  inter- 
columnar  fibers  of  the  aponeurotic  insertion  divided.  Reflection  of  the  pillars 
of  the  ring  gives  the  view  shown  in  the  accompanying  sketch  (Fig.  1164). 
In  the  Halsted  operation  at  this  stage  the  internal  oblique  fibers  are  divided, 
preliminary  cocainization  of  the  edge  of  the  muscle  being  necessary  for  the 


ILIO-HYPOGASTRIC  N 
ILIO  -  INGUINAL  N 


«>f 


INCISION  THROUGH 

INT. 

OBLIQUE   M. 


Fig.  1164. — Operation  for  the  la 


ore  of  inguinal  hernia  under  local  anaesthesia, 
Cushing's  method. 


reasons  given  above.  Tbere  is,  under  ordinary  circumstances,  no  further  need 
of  the  anaesthetic,  as  we  are  working  in  an  area  freed  from  all  sensation. 
The  combined  ilio-iuguinal  and  genital  branch,  which  has  been  cocainized 
at  the  outer  limit  of  its  exposure,  is  now  reflected  to  one  side  or  the  other, 
care  being  taken  not  to  divide  it,  since  this  leads  apparently  to  a  more  or 
less  permanent  paralysis  of  the  cremaster,  which  is  to  be  avoided.  I  believe 
the  accidental  division  of  this  nerve  leads  to  the  great  relaxation  of  the 
scrotum  so  often  seen  after  hernia  and  varicocele  operations.  In  the  latter 
operation,  especially,  it  would  be  detrimental  to  the  best  interests  of  a  suc- 
cessful result  to  interfere  with  the  cremasteric  function  in  any  way.  The 
remainder  of  the  operation — the  exposure  of  the  sac  and  cord  after  a  longi- 
tudinal division  of  the  infundibuliform  fascia,  the  amputation  of  the  sac  at 
its  neck  and  closure  of  the  peritoneal  opening,  the  excision  of  the  fundus 
of  the  sac,  division  of  the  cord,  and  castration,  if  deemed  advisable — may  now 


OPKUATIONS   ON    VISCKKA   CONNKCTKD    WII'll    I'KIII'I'ON JOUM.     V>4r) 

be  (loiic  ]>riict,ic;illy  witliout  piiin.  Oeciisioiuilly,  liuwever,  sojiic  stniy  filjcrs 
of  the  gcnito-crural  iiuiy  l)c  eiicouiitercHl  uboiit  the  neck  of  tlio  sac,  and  also 
during  castration  I  have  found  that  ligation  of  the  veins  at  the  lower  pole 
of  the  testiclo  may  be  painful,  though  division  of  the  cord  above  is  not. 
Possibly  the  superticial  pci-ineal  branches  which  have  been  unana'sthetized 
furnish  nerves  to  this  lower  blood  supply." 

The  Remarks. — Those  patients  who  bear  slight  j)ain  badly,  those  in 
whom  the  inhibiting  inlluence  of  the  drug  is  transient  or  exhausted,  and 
those  with  strong  imaginations,  may  require  the  aid  of  a  little  morpliin,  and 
perhaps  now  and  then  a  few  breaths  of  chloroform.  A  careful  study  should 
be  nuide  of  the  course  and  supply  of  the  sensitive  nerves  involved  in  the 
operation  before  attemi)ting  the  procedure,  to  avoid  direct  injury  of  them, 
also  to  lessen  needless  inlliction  of  pain.  Anaesthesia  of  individual  trunks 
and  their  areas  of  distribution  is  secured  by  direct  injection  into  the  trunks 
of  a  half  of  one-per-eent  solution. 

Handling  and  repair  of  healthy  intestine  do  not  cause  especial  pain, 
therefore  local  anaesthesia  is  not  needed.  However,  the  manipulation  of 
strangulated  and  diseased  intestine  causes  referred  pain,  usually  to  the  epi- 
gastrium. Sterilization  of  food  and  aseptic  treatment  of  the  mouth  decid- 
edly lessens  the  putrefactive  changes  of  intestinal  torpors  and  obstruction. 

The  Results. — Twenty-five  cases  of  operation  for  radical  cure  are  re- 
ported ;  6  were  strangulated,  of  which  1  died ;  the  remaining  19  recovered. 
Thirteen  of  the  entire  number  were  above  sixty  years  of  age,  7  of  which 
were  seventy  and  over. 


chaptp:r  XV. 

OFF  RATI  nXS   OX   THE  AXVS  AXD  liECrUM. 

SixcE  the  approach  to  the  rectum  and  lower  intestine  is  by  way  of  the 
anus,  and  as  the  anus  is  subject  to  disease  amenable  to  surgical  effort,  to  it 
will  be  given  the  primary  consideration. 

The  Examination  of  the  Anus. — Examination  of  the  anus  is  a  necessary 
preliminary  to  diagnosis  and  operations  directed  to  the  lower  end  of  the 
bowel.  The  examination  can  be  conducted  with  the  patient  placed  in  any 
one  of  the  following  positions :  1,  the  knee  and  elbow  position ;  2,  upon  the 
back,  with  the  thighs  drawn  upward ;  3,  upon  the  right  side,  with  the  knees 
drawn  upon  the  abdomen ;  4,  with  the  patient  kneeling  on  the  seat  of  a 
chair  and  leaning  over  its  back.  Usually  the  patient  is  placed  on  the  back 
in  the  lithotomy  attitude.  However,  the  most  comfortable  and  delicate  posi- 
tion is  upon  the  side.  It  is  hardly  necessary  to  add  that  the  surgeon  should 
be  familiar  with  the  normal  characteristics  of  the  parts,  not  only  those  relat- 
ing to  the  appearance,  but  also  to  their  sensibility  and 
])liancy.  On  inspection,  the  wrinkled  aspect  of  the  anal 
opening  and  of  the  contiguous  integument,  the  condition 
of  the  blood-vessels  about  the  opening,  and  the  white  line 
at  the  muco-cutaneous  junction,  corresponding  to  the  in- 
terval between  the  internal  and  external  sphincters,  should 
be  noticed.  The  degree  of  sphincteric  contraction,  and 
tlie  irritability  of  the  patient,  as  evidenced  by  the  intro- 
duction of  the  finger  into  the  anus,  are  important  items 
relating  to  cure.  Thorough  cleansing  of  the  bowel,  and 
the  final  escape  of  the  fluids  employed  for  this  purpose, 
should  be  secured  before  any  special  attemj)t  is  made  to 
examine  the  anus  or  rectum. 

Imperforate  Anus. — Imperforate  anus  is  characterized 
l)y  a  layer  of  tissue  of  variable  thickness  which  exists  be- 
tween the  normal  site  of  the  external  opening  and  the 
lower  extremity  of  the  rectum.     It  may  be  simply  a  thin 
layer  of  fibro-cellular  tissue,  which,  by  projection,  indi- 
cates the  nearness  of  the  loaded  bowel.      In  these  cases 
the  active  emotions  of  the  child  may  be  noted  by  the  move- 
ments of  the  interposed  membrane,  and  a  positive  diag- 
nosis can  be  made  by  a  hypodermatic  puncture.     If  the  septum  be  thin,  a 
longitudinal  or  crucial  incision,  or  even  a  simple  puncture,  followed  by  the 
946 


Fig.  1165.— Rectal 
bougies.  a.  Cy- 
lindrical, b.  Con- 
ical shaped. 


OI'ERATIONS   OX   TIIK    ANTS    AND    RKCTLTM. 


947 


careful  introduction  (»f  a  wrll-oilcd  linger,  will  be  a  sufticient  operative  inter- 
ference, especially  if  afterward  the  extremity  of  a  suitable  sized  rectal  bougie 
be  occasionally  introduced  (Fig.  11  Go).  If  the  membrane  be  of  sufficient  den- 
sity to  interpose  an  obstacle  after  its  division,  it  sbould  be  trimmed  away, 
care  being  taken  not  to  include  tbe  structure  proi)er  of  the  opening.  Severe 
and  even  fatal  luemorrhage  has  been  known  to  follow  these  apparently  trivial 
0})erat i ve  j)r( x'od u res. 

Absence  of  the  Anus  (Fig.  110*3). — in  this  deformity  all  trace  of  the  open- 
ing is  absent,  and  the  median  rhaphe  may  extend  continuously  from  the 
scrotum  to  the  tip  of  the  coccyx.  The  fibro-cellular  interval  may  be  either 
thin  or  of  extreme  thickness.  If  thin,  the  previously  detailed  signs  of  im- 
perforate anus  may  be  evident.  When,  however,  they  are  not  present,  tlie 
occlusion  is  of  considerable  thickness,  and  may  even  involve  the  entire 
lengtii  of  the  rectum  itself  (Fig.  1167).     In  the  latter  instance  the  sphincter 


Fig.  11  G6. — Absence  of  anus. 


Fig.  1167. — Absence  of  anus  and  rectum. 


is  sometimes  wanting.  The  rectal  pouch  may  hang  loosely  in  the  pelvic  or 
abdominal  cavity,  or  be  attached  to  some  contiguous  structure.  A  distinct 
fibrous  band  may  lead  from  the  skin  to  the  rectal  pouch,  or  only  cellular 
tissue  may  intervene. 

The  operation  for  relief  consists  in  first  placing  the  patient,  properly 
anaesthetized,  in  the  dorsal  position  with  the  pelvis  elevated.  Then  intro- 
duce a  sound  into  the  bladder  if  the  patient  be  a  male,  or  into  the  vagina 
if  a  female,  and  make  a  vertical  incision  in  the  median  line  from  just  behind 
the  scrotum  or  vagina,  as  the  case  may  be,  to  the  tip  of  the  coccyx  (Fig. 
1108);  deepen  it  cautiously  up  and  backward,  shortening  each  succeeding 
cut,  and  carefully  feel  for  the  fluctuating  extremity  of  the  gut.  The  latter 
is  sometimes  located  posterior  to  the  central  line,  and  must  be  sought  for 
near  the  hollow  of  tlie  sacrum.-  During  the  entire  progress  of  the  dissec- 
tion the  situation  of  the  vagina  or  urethra  must  be  marked  by  the  location 
66 


948 


OPERATIVE  SURGERY. 


of   the   sound    previously  introduced.     When   the   dark-brown,  fluctuating 
extremity  of  the  gut  is  detected,  the  introduction  of  a  hypodermic  needle 

will   settle  all   doubt.     The  gut 
end  should  then  be  seized   by  a 
strong,     toothed     forceps     (Fig. 
11G9),  and   drawn    firmly  down- 
ward, while  its  connections  with 
the  surrounding  tissues  are  sepa- 
rated by  the  scissors  and  fingers. 
As  soon  as  the  cul-de-sac  is  drawn 
down  to  a  level  with 
the   external   opening, 
two     short      ligatures 
are  passed  transversely 
through   the    sides  of 
the    wound    (J,  e),   or 
through  its  anterior  and  posterior 
extremities,  transfixing  in  either 
instance  the  walls  of  the  bowel  in 
their  passage,  but   not    entering 
the  lumen  of  the  gut.      Protect 
the  raw  surfaces  with  lint  satu- 
rated   with    carbolized    oil,   then 
open  the  sac  between  the  ligatures 


Fig.  1168. — Operation  for  absence  of  anus.  a. 
Border  of  cutaneous  incision,  b.  End  of 
bowel,  c.  Perirectal  tissue,  d.  Extremity 
of  coccvx.     e.  Scrotum. 


and  allow    the   contents  to  escape ;   after 
having  thoroughly  cleansed  the  parts,  re- 
move   the   lint   and  unite   the    border   of 
the  sac  with  the  anus  by  interrupted  silk- 
worm-gnt    sutures    (Fig.    1170).     Cleanse 
the    bowel   thoroughly,   and    introduce   a 
small,  coaptating  plug  of  iodo- 
form gauze  perforated  by  a  good- 
sized    rubber    tube    (Fig. 
1171,  e)    to   exclude   fa?eal 
matter   from    the    line    of 
sewing,  and  to  permit  the 
escape  of   intestinal  gases  at  the  same 
time.      The  mucous  membrane    should 
be  closely  adjusted  to  the  integument,  in 
order  to  secure  perfect  union  and  pre- 
vent  the   contact  of   the   raw   surfaces 
with  the  discharges.     If  it  be  impossible 

to  draw  the  end  of  the  gut  down  to  the    Fig.   1169.— Operation    for    absence   of 

.  1  •         •,  I'-Ti-i.         anus.      a.  Sutures   at   anterior  aspect 

external  opening,  it  can  be  incised  at  its       ^f  ^^^^.i.  ^^e  posterior  one  may  pass 

lower  extremitv,  and  the  discharges  al-       through   the  wall  of  the  cul-de-mc. 

lowpd  tn  p<;cflTiP  nvpr  thp   Inwpr  <?nrfacps         *•  ''■  ^"^"''65  at  sides  of  wound,  both 
lowea  to  escape  over  tne  lower  surraces,       transfixin-  the  wall  of  the  nd-de-sae. 

which  are  kept  open  by  the  use  of  the       d.  Rectal  cul-de-sac.    f.  Scrotum. 


OPKliATloNS   ON   TIIH   ANUS   AND    UKCTLM. 


949 


boufries;  or  the  t-occyx  can  be  removed,  as  recoriiitieiided  by  Verneuil,  and 
the  extremity  of  the  bowel  drawn  tlirougli  the  gap  ami  united  to  the  integu- 
ment as  before. 

77/e  Remarks. — The  usual  distance  between  the  pouch  and  the  perinanim 
is  about  two  inches,  and  tiie  site  can  be  well  located  by  the  occasional  intro- 
duction of  the  hyjH)dermic  syringe.  Fatal  cellulitis  may  follow  the  dissec- 
tion directly  or  from  the  efforts  to  maintain  the  patency  of  the  new  canal 

(Fig.  iiro)' 

Fistula  in  Ano. — A  fistula  here,  as  elsewhere,  is  a  sinus,  which  in  this 
case  leads  into  the  cavity  of  an  abscess  located  near  to  the  rectum.  It  may 
be  either  complete  or  incomplete;  if  of  the  latter  variety,  it  may  be  an  in- 
complete internal  or  external 
fistula  (Fig.  117:3).  The  com- 
plete form  (b)  is  the  more  fre- 
quent. In  either  variety  the 
openings  are  usually  situated 
within  an  inch  or  less  of  the 
anus.  These  fistula?  are  of  de- 
vious shapes  and  of  varying  ex- 
tent, the  horseshoe  variety  (page 
954)  often  being  very  perplexing. 

The  Examinatioyi  for  the  De- 
tection of  a  Fistulous  Openi)tg. — 
Evacuate  the  bowel  by  a  cathar- 
tic and  an  enema ;  place  the  pa- 
tient on  the  back  or  side,  and  in- 
troduce the  well-oiled  index  fin- 
ger of  the  hand  corresponding 
to  the  side  of  the  patient  pre- 
senting the  external  opening  in- 
to the  rectum.  The  careful 
movement  of  the  end  of  the 
finger  over  the  mucous  mem- 
brane will  often  detect  a  nipple- 
like projection  indicating  the  internal  opening.  If  a  flexible  probe  be 
introduced  through  the  external  opening,  it  can,  with  a  little  care,  be  carried 
into  the  lumen  of  the  rectum.  Sometimes,  however,  the  end  of  the  probe 
will  be  felt  separated  from  the  finger  by  only  the  thin  mucous  lining  of 
the  gut;  this  may  be  due  to  the  inability  to  find  the  internal  opening  or  to 
its  non-existence.  In  either  case  the  thin  wall  should  be  perforated  by 
the  instrument,  thus  producing  a  complete  fistula.  It  not  infrequently 
happens  that  more  than  one  opening  (c,  e)  communicates  with  the  seat  of 
the  original  abscess,  (^  (^jg-  11T3),  and  also  that  the  mucous  membrane  is 
undermined  to  a  considerable  extent  above  a  previously  existing  abscess 
(Fig.  1174,  a). 

The  Remarks. — It  is  of  importance  to  remember  that  the  introduction 
of  the  finger  or  the  probe  often  produces  such  a  degree  of  contraction  of 


Fig.  1170. — Operation  for  absence  of  anus.  a. 
Primary  anterior  sutures,  b,  c.  Lateral  su- 
tures tied.  /,  c.  Anterior  and  posterior  su- 
tures transfixing  wall  of  gut.  d.  Example  of 
suture  of  gut  to  border  of  wound. 


950 


OPERATIVE  SURGERY. 


Fig    1171. — Instruments  employed  in  operations  on  the  anus. 

a.  Scalpels.  6.  Bistouries,  r.  Forcipressure.  (Z.  Speculum,  e.  Rubber  tulie  mounted  with 
gauze  for  introduction  into  the  anus  and  rectum.  /.  Dissecting  and  mouse-tooth 
forceps,  h.  Strong  hook  forceps,  i.  Grooved  director,  j.  Blunt  retractor,  k.  Pile 
forceps.  I.  Needle  holder,  m.  Long-nosed  clamp  forceps,  n.  Scoop,  o.  Sponge 
holder,  p.  Tenaculum,  q.  Pile  clamp,  r.  Silver  probe,  s.  Curved  and  straight 
scissors,  t.  Ligatures  armed  with  needles,  u.  Chromicized  catgut  and  silkworm 
gut.     V.  Long  and  short  needles.     Sponges,  wipers,  and  ligatures  are  required. 


UI'IIKA'I'IONS   ON    'I'llK    AXIS    AND    KKC'll M. 


951 


tlu'  si)liiiu'li'r  !is  to  |pi-cvciit  till'  passajfe  of  llic  lattiT  \villi(jiiL  ;j;reut  ditlicultv 
along  the  sinus  iiitn  ilic  gut;  tlaTcfore  the  altt'nij)t  to  puss  it  should  not  he 
made  until  the  muscular  contraction  ceases.  It  may  be  advisable  to  paralyze 
the  sphincter  by  overdistcntion  before  dividing  the  sinus;  this  causes  the 


Fui.  117~. — <(.  Anus.  r.  Uec- 
turn.  b.  Cdinplete  fistula. 
c.  Incomplete  interniil  fis- 
tula. (I.  Incomplete  exter- 
nal fistula. 


Fig.  1173.— Fistula  in  ano 
with  (Inal  openings  (c,  e). 


Fui.  1174. — Fistula  in  ano 
with  extensive  under- 
mining of  mucous  mem- 
brane (i). 


parts  to  remain  at  rest,  adding  to  the  comfort  of  the  patient  and  hasten- 
ing recovery.  It  can  be  accomplished  by  inserting  the  thumbs  through  the 
anus  back  to  back,  drawing  them  apart,  or  flexing  the  first  joints  and  with- 
drawing the  digits  simultaneously  (Fig.  1175),  or  by  separation  of  them,  or 
the  use  of  a  speculum  designed  for  the  purpose  (Fig.  1170). 

The  Operation  Treatment. —  The  accepted  plan  of  treatment — division  of 
the  walls  of  the  sinus — can  be  accomplished  by  direct  incision,  by  ligature^ 
or  by  the  galvano-cautery.  The 
first  method  is  commonly  employed. 


Fi(i.  1176.— Thebauil's 
dilating  speculum. 


Fig.  1175. — The  act  of  paralyzing  the 
sphincter. 

For  this  purpose  the  bowel  should  be  thoroughly  evacuated  by  a  brisk  cathar- 
tic on  the  day  preceding  the  operation,  and  a  light  diet  should  follow.  On 
the  day  of  the  operation  the  bowel  should  be  well  cleansed  by  one  or  two  copi- 
ous enemata,  which  should  have  escaped  before  the  operation  is  commenced. 


952 


OPERATIVE   SURGERY. 


The  Operation  by  Direct  Incision. — Place  the  patient  on  the  back  and  give 
an  anaesthetic;  pass  the  finger  into  the  bowel,  as  before  described ;  introduce 
a  grooved  director  through  the  sinus  into  the  bowel ;  if  the  end  of  the 
director  can  be  turned  out  (Fig.  1177),  divide  the  sinus  upon  this  instru- 
ment; if  not,  press  its  end  against  the  finger,  and  pass  a  probe-pointed 
bistoury  along  the  groove  into  the  bowel,  after  wliich  the  director  may  be 


Fig.  1177.— Operation  for 
fistula  in  ano,  shallow 
sinus.  End  of  grooved  di- 
rector turned  out  through 
anus. 


Fig.  1178.  — Operation  for 
fistuhi  in  ano,  deep  sinus. 
End  of  finger  in  contact 
with  extremity  of  grooved 
director. 


Fig.  1 1 7!).— Operation  for 
fistula  in  ano.  Piece  of 
wood  substituted  for 
finger. 


withdrawn,  the  point  of  the  bistoury  pressed  against  tlie  finger  and  the 
sinus  cut  outward  with  the  point  thus  protected  (Fig.  11 78).  For  the  fin- 
ger may  be  substituted  a  wooden  director  introduced  into  the  bowel,  by  aid 
of  which  division  is  made  (Fig.  1179).  The  scissors  may  be  employed  instead 
of  the  knife,  either  with  (Fig.  1180)  or  without  the  grooved  director.  When- 
ever the  depth  of  the  sinus  demands  the  division  of  the  entire  thickness  of 
the  internal  sphincter,  it  should  be  done  at  right  angles  with  the  course  of 
the  fibers,  to  avoid,  as  far  as  possible,  the  danger  of  incontinence  of  flatus 
and  faeces. 

AVhile  each  sinus  should  be  opened,  still,  when  possible  to  avoid  it,  the 
sphincter  should  not  be  divided  at  all ;  and,  at  all  events,  only  at  one  situa- 
tion at  a  time,  in  order  that  its  integrity  can  be  the  better  restored  ;  when 
practicable,  a  small  portion  of  the  circular  fibers  should  be 
preserved  with  the  same  object  in  view.  It  is  not  neces- 
sary to  divide  the  walls  of  the  abscess  above  the  open- 
ing into  the  gut  (Fig.  1174,  a),  since  the  drainage 
due  to  the  division  of  the 
tissues  below  permits  a  rapid 
healing  of  this  portion.  As 
soon  as  the 
sinuses  are 
opened,  their 
pseudo-mem- 
branous lin- 
ings should  be  scraped  with  a  scoop  or  touched  with  a  therm o-cautery, 
all  haemorrhage  stopped,  the  cut  packed  with  oakum,  marine  lint,  or  iodo- 
formized  gauze,  a  T-bandage  applied,  the  patient  placed  in  bed  with  limbs 


Fig.  1180. — Operation  for  fistula  in  ano. 

scissors. 


Allinyham's  director 


OPKRATIONS   ON    'II IK    ANTS    AND    IJKCIC.M. 


953 


extended,  iind  morpliiii  or  oi)iinii  si)!iriii^'ly  <^iven  to  relieve  all  irritatioa 
ciud  to  produce  i)assive  constipation  of  the  bowels.  The  wound  is  dressed 
once  or  twice  daily,  according  to  the  demands  of  cleanliness,  wliich  should 
be  strictly  enforced.  The  food  .should  be  light,  and  not  of  a  nature  likely 
to  leave  a  resiihie.  In  three  or  four  days  make  use  of  a  mild  cathartic  in 
conjunction  with  a  copious  enema  to  secure  a  lluid  movement. 

Tlie  PrecautiotDi. — I  hemorrhage  of  any  importance  is  rarely  seen — pack- 
ing and  ligature  will  readily  control  it;  concealed  haemorrhage — i.  e.,  free 
bleeding  into  the  rectum — may  be  troublesome  unless  anticipated  and  pre- 
vented. Kapid  healing  of  the  freshly  cut  surfaces  without  repair  of  the 
fistulous  canal  should  be  prevented,  otherwise  the  original  character  of  the 
atfection  will  soon  be  restored.  The  separation  of  the  bordci's  of  the  wound 
with  a  small  amount  of  gauze  or  by  frequent  introduction  of  the  finger  will 
prevent  premature  union  and  foster  granulation  of  the  fistulous  tract.  On 
the  other  hand,  too  frequent  dressing  or  firm  packing,  and  walking  about, 
may  delay  and  even  defeat  repair  of  the  parts.  The  devious  courses  of  fis- 
tula sliould  be  followed  and  opened  unless  their  course  requires  more  than 
one  division  of  the  sphincter,  when  repeated  operations  at  distinct  intervals 
should  be  performed  rather  than  imperil  the  sphincteric  power  by  cutting 
all  at  a  single  sitting.  A  fistula  in  ano  in  tuberculosis  often  heals  with 
difficulty  and  after  much  delay,  especially  if  associated  with  local  tubercu- 
losis or  great  depression  from  constitutional  involvement.  The  author  is 
not  disposed  to  operate  on  fistula  in  auo  in  tuberculous  patients,  unless  the 
fistula  itself  constitutes  a  positive  affliction. 


Fig.  1181.— Bivalve 
speculum. 


Fig.  1182.— Williams's 
rectal  speculum. 


Fig.  1183. — AUinghara's  rectal 
speculum. 


The  Comments. — The  walls  of  fistula?  should  be  scraped  after  division  to 
facilitate  healing,  and  all  gristly,  undermined,  and  granulation  tissue  and 
complicating  haemorrhoids  removed.      The  detection  of  a  communication 


954 


OPERATIVE  SURGERY. 


Fio.  1184.- 


-Fistula  in  ano,  equilateral  horseshoe  form. 
Line  of  incision. 


within  is  often  difficult  and  even  impossible  except  with  the  use  of  injec- 
tions.    The  injection  of  milk,  peroxide  of  hydrogen,  or  of  a  weak  solution 

of  iodine  with  starched 
gauze  in  the  rectum,  will 
reveal  the  slightest  com- 
munication with  the  bowel, 
unless  the  opening  within 
is  closed  by  needless  pres- 
sure. One  of  the  various 
forms  of  rectal  specula?  may 
be  of  service  in  locating  the 
opening  (Figs.  1181,  118"^, 
and  1183).  Fistulas  vary 
much  in  their  extent  and 
relation  to  the  gut.  The 
horseshoe  (Fig.  1184)  vari- 
ety has  an  opening  within 
and  one  at  either  side  of  the 
anus  without,  a  sinus  com- 
munication existing  be- 
tween the  outer  openings, 
and  both  communicating 
with  the  inner  one  (Fig. 
1185).  The  internal  sinus 
should  be  slit  up  by  an  in- 
cision which  emerges  at  the 
skin  margin  at  a  point  equi- 
distant between  the  two 
other  openings  if  possible. 
The  curved  sinus  is  then 
divided  in  either  direction 
to  the  openings  without  in- 
volvement of  the  gut  (Fig. 
1186).  Only  one  division 
into  the  gut  should  be  made, 
unless  more  than  one  open- 
ing be  present  there,  and 
the  openings  be  independ- 
ent of  each  other. 

Direct  Incision  with 
Closure  (S.  Smith).— If  the 
extent  of  the  sinus  will  per- 
mit it,  the  entire  tract 
should  be  removed  by  dis- 
section and  the  resulting 
wound  closed  by  catgut  sutures  carried  deep  enough  to  bring  the  walls  of 
the  wound  in  contact  with  each  other.     Two  rows  of  chromicized  catgut  su- 


FiG.  1185. — Fistula  in  ano,  equilateral  horseshoe  form 
Line  of  incision. 


Fig.  1186. 


-Fistula  in  ann.  irregular  horseshoe  form. 
Line  of  incision. 


OPERATIONS   ON    TIIK    ANl'S   AND    KllC'I'l'M. 


i>r>5 


tures  s 
of  the 


nould  bu 
mucous 


employed  :  one,  a  deep  row,  wliieli  should  brin;,'  the  borders 
membrane  uud  the  deeper  structures  together,  while  the 
other  should  unite  the  superdcial  parts.  In  this  manner 
union  by  first  intenti(jn  may  be  secured,  tlius  shortening 
the  period  of  recovery,  and  obviating  all  danger  of  fa;cal 
incontinence  dependent  upon  the  incomplete  closure, 
which  sometimes  occurs  when  the  cut  is  deep  and  is  per- 
mitted to  heal  from  the  bottom.  If,  however,  there  be  a 
cavity  remaining  at  the  upper  end  of  the  sinus,  or  if  any 
portionof  the  fistula  be  not  dissected  out,  the  recovery  by 
rapid  healing  will  be  retarded  if  not  entirely  prevented. 
The  author  has  carried  into  effect  the  proposition  of 
prompt  closure  of  the  wound  by  sewing  in  repeated  in- 
stances, and  usually  with  success.  In  no  instance  has 
harm  ever  followed  the  attempt.  CJreat  care  should  be 
exercised  to  secure  fluid  movements  at  first  to  prevent  un- 
due strain  on  the  lines  of  suture. 

The  Treatment  by  Ligature. — The  elastic  ligature  is 
the  only  form  worthy  of  consideration.     The  ligature  con- 


FiG.  1188. — Operation  for  fistula  in  ano.     The  probe   as  elastic 
ligature  carrier. 

sists  of  a  rubber  cord  about  one  tenth  of  an  inch  in  diam- 
FiG.  1187.— Ailing-  eter.  The  cord  is  carried  through  the  sinus  into  the  gut 
lu^e'clm'er''^'''  by  a  special  instrument  (Fig.  1187),  or  by  a  long,  large- 

eved  silver  probe,  so  diverted  as  to  escape  at  the  anus 
(Fig.  1188),  the  inner  extremity  drawn  out  through  the  anus  and  the  ends 
tied  firmly  together,  after  any  integument  which  might  be  included  in  its 
grasp  has  been  first  divided,  to  prevent  the  pain  and  delay  incident  to  the 
division  of  its  peculiar  structure  by  the  constricting  agent.  The  probe  and 
a  strong  silk  thread  admirably  meet  the  requirements,  as  the  latter,  after 
being  passed  through  the  sinus  and  attached  to  the  rubber  cord,  may  easily 
draw  the  latter  into  position.  It  is  sometimes  difficult  to  tie  a  knot  securely 
in  the  rubber  cord.  Still,  this  can  be  accomplished  easily  by  tying  the  first 
half  of  the  knot  over  a  silk  ligature  placed  at  right  angles  to  the  course  of 
the  elastic  one,  and  then  tying  the  silk  ligature  firmly  around  the  half  knot. 
This  holds  the  elastic  cord  securely  while  the  knot  of  the  rubber  cord  is  com- 
pleted.    The  elastic  ligature  will  cut  its  way  through  in  six  or  eight  days. 


956 


OPERATIVE   SURGERY. 


This  method  possesses  some  advantages  over  that  of  incision,  among 
which  may  be  noted  that,  in  simple  cases,  little  or  no  ])ain  is  inflicted,  and 
tlie  patient  can  walk  without  any  especial  danj^er. 

Timid  patients  refusing  the  use  of  the  knife  will  often  submit  to  the 
employment  of  the  elastic  ligature.  The  cure  by  ligature  is  not  attended 
with  bleeding,  which  is  an  advantage  when  vessels  of  unusual  size  may  be 
implicated,  or  when  an  undue  tendency  to  hemorrhage  exists.  It  is  the  best 
method  in  phthisical  jiatients,  for  manifest  reasons.  It  can  be  employed  in 
all  cases  where  but  a  single  sinus  exists;  if,  however,  a  second  be  present, 
the  result  must  be  of  necessity  unsatisfactory,  as  its  employment  then  involves 
a  repetition  of  tlie  operation  or  the  use  of  the  knife. 

Tlie  gidvano-cautenj  (Fig.  102)  does  not  secure  better  results  than  inci- 
sion, and  is  mucli  more  cumbersome  in  its  application  ;  still,  it  is  useful  when 
dangerous  ha?morrliage  is  apprehended. 

The  Results. — The  death  rate  is  difiicult  to  estimate,  because  of  the  com- 
parative innocence,  but  at  the  worst  it  forms  no  significant  product  of  the 
procedure.  However,  certain  sequels  of  the  operation  are  of  special  signifi- 
cance. 

The  important  sequels  of  operation  for  fistula  in  ano  are  incontinence 
of  faeces  and  gas,  and  prolapse  of  the  mucous  membrane  and  possibly  of  the 
bowel  as  well.  Various  reasons  are  assigned  for  the  condition  that  permits 
of  their  occurrence.  Females  are  more  subject  to  incontinence  than  males. 
Repeated,  oblique,  and  high  division  of  the  sphincter  and  division  at  the 
junction  with  the  sphincter  vaginse  should  be  avoided  if  possible  because  of 


Fig.  1189. — Plastic  operation  for  cure 
of  incontinence  of  f.eces,  unilateral. 


Fig.  1100. — Plastic  ojjeration  for  cure  of  in- 
continence of  faeces,  bilateral. 


their  liability  to  cause  incontinence.  Often  after  ordinary  operations  several 
weeks  are  required  before  complete  control  of  the  sphincter  is  secured. 
Irrespective  of  the  cause,  they  are  best  obviated  by  a  limited  impairment 
of  the  sphincter,  and  close  union  and  prompt  healing  of  the  divided  ends 


Ol'KKA'rioNS   ()\    TIIH    ANUS   AND    RECTUM. 


957 


Fig.  llOl.^OpLruliuii  by  cautfiiziitiou  for  cure  of  incon- 
tinence of  fiBces. 


ill  the  time  of  djierution.  I'lni  viclhoils  of  v arc  arc  rmnnmcndi'd :  1,  the 
eiii[il(tyiiK'iit  of  phistic  re});iir;  ^,  the  use  of  the  actual  cautery.  In,  the 
fonner  inetliod  a  V-shaped  incision  is  made  witii  the  apex  otitwai'd  and  with 
the  lines  of  incision  sodifccted  as  to  exj)osc  the  divided  enils  of  tlie  spliincter 
(Figs.  1189  and  1190),  which  are  then  freshened  and  drawn  together  by  means 
of  sutnres  jiassed  deeply  and  retained  in  place  during  healing  of  the  wound. 
The  anal  mucous  membrane  at  the  base  of  the  triangle  should  not  be  divided, 
as  it  serves  to  protect  the  severed  tissues  from  infection,  and  affords  of  itself 
a  limited  obstacle  to  the 
escape  of  rectal  matter. 
And  esj)ccially  is  this 
true  if  the  membrane  be 
separated  from  the  sub- 
jacent tissues  and  drawn 
downward  and  stitched 
to  the  anal  border  at  the 
seat  of  repair  of  the 
sphincter.  Vertical  sub- 
cutaneous division  of  the 
inner  fibers  of  the  sphinc- 
ter, at  a  little  distance 
from  either  side  of  the 
line  of  union  of  the  di- 
vided ends,  will  sometimes  aid  the  final  repair,  by  lessening  the  tension  of 
the  inner  and  shorter  sphiucteric  fibers.  The  secondary  divisions  heal 
promptly. 

In  the  latter  method,  deep,  outward  radiating  divisions  are  made  with 
actual  cautery,  with  or  without  linear  cauterization  of  the  mucous  mem- 
brane of  the  lower  end  of  the  rectum,  at  points  corresponding  to  the  inner 
extremities  of  the  radiating  incisions  (Fig.  1191).  The  radiating  burns 
extend  from  within  the  anus  outward  for  an  inch,  down  to  the  sphinc- 
ter. In  any  method  of  repair  the  anus  and  rectum  should  be  kept  as  quiet 
as  possible,  and  2:)erfect  cleanliness  enforced.  The  many  details  of  the 
technique  of  repair  will  be  found  only  in  treatises  devoted  especially  to 
rectal  disease. 

Hsemorrhoids. — A  varicose  condition  of  the  ano-rectal  veins  is  a  frequent 
affection,  to  which  the  term  hajmorrhoids  or  piles  is  applied.  Tiuo  distinct 
varieties  of  haemorrhoids  are  recognized — external  and  internal  hsemorrhoids. 
A  combination  of  the  two — intero-external — is  not  infrequently  seen.  The 
external  are  located  without  the  bowel  and  are  intimately  connected  with  the 
anal  border.  The  internal  are  located  within  the  bowel  and  are  not  seen 
externally  except  when  prolapsed.  In  either  situation  the  growths  vary  in 
shape,  size,  and  extent  of  attachment.  External  piles  are  usually  globular, 
with  a  sessile  or  pedunculated  base,  and  an  inner  mucous  and  outer  cutane- 
ous surface.  Internal  piles  may  be  either  pedunculated,  sessile,  columnar, 
etc.,  shaped  according  to  the  degree  and  extent  of  the  dilatation.  Prolapsus 
ani  (Fig.  120G)  sometimes  attends  the  haemorrhoids. 


958  OPERATIVE   SURGERY. 

The  preparatonj  LrealinenL  consists  in  securing  a  free  evacuation  of  the 
bowels  twenty-four  or  thirty-six  liours  before  operation,  followed  by  an  enema 
the  nigh"t  before.  Care  should  be  taken  to  eliminate  from  the  rectum  any 
retained  fttces  or  fluid  injection,  so  as  to  avoid  the  unj)leasant  catastrophe 
and  wound  infection  that  might  happen  from  an  unanticipated  discharge 
during  operation. 

Various  operative  methods  of  treatment  have  been  devised  for  cure  of 
haemorrhoids,  the  most  important  of  which  are  by:  a,  incision  ;  t),  excision; 
c, ligature  with  excision  ;  d,  crushing ;  e,  clamp  and  cautery ;  and/,  injection. 

The  Incision  Method. — Incision  is  employed  in  the  treatment  of  recent 
inflamed  and  distended  h;v^morrhoids.  After  thorough  cleansing  of  the  parts 
place  the  patient  on  the  side,  with  the  thighs  flexed  on  the  abdomen  and  the 
nates  separated ;  seize  the  tumor  between  the  thumb  and  finger  and  slit  it 
open  from  within  outward  in  the  direction  of  the  radiating  folds  of  the  anus 
with  a  sharp-pointed  curved  bistoury ;  turn  out  the  clot,  cleanse  the  wound, 
and  pack  it  gently  with  iodoform  gauze,  to  exclude  infection  and  prevent 
premature  union.  Under  the  influence  of  daily  dressing  and  quiet,  a  rapid 
and  safe  cure  ensues. 

The  Excision  Methods. — Excision  alone  is  emj^lo^'ed  in  the  removal  of 
quiescent  haemorrhoids,  and,  combined  with  ligature,  is  practiced  in  the 
removal  of  both  limited  and  extended  hemorrhoidal  growths.  The  integu- 
mentary tabs — the  sequel  of  external  jiiles — can  be  cut  off  directly,  on  a 
line  with  the  surface  to  which  they  are  attached,  with  scissors.  The  little 
hemorrhage  that  follows  is  easily  controlled  and  healing  facilitated  by  closing 
the  cut  siirface  with  a  suture  or  two  of  fine  catgut.  Xot  infrequently,  how- 
ever, in  this  class  of  cases  the  hemorrhoids  become  distended  again  with 
blood,  very  cedematous,  exceedingly  painful,  and  in  rare  instances  gangre- 
nous. They  are  then  readily  removed  by  ligature  and  excision,  or  clamp 
and  cautery.  Also  direct  excision  can  be  practiced  in  those  cases  in  which 
three  or  four  well-defined  tumors  with  distinct  bases  are  present,  by  seizing 
the  tumor  at  the  base  with  narrow  forceps,  and,  while  the  base  yet  remains 
in  the  grasp  of  the  instrument,  the  pile  is  removed.  The  base  is  twisted  or 
tied  as  may  be  needed,  to  prevent  bleeding.  The  following  method  is  much 
better  than  this  one  in  this  class  of  cases. 

Allingham's  Method  {Longitudinal  Excision  and  Ligature). — Give  an 
anesthetic,  place  the  patient  on  the  back  with  the  buttocks  near  the  edge  of 
the  table,  thighs  flexed  and  separated  with  the  Clover's  crutch  and  nates 
drawn  apart.  Dilate  the  sphincter  completely  ;  expose  the  lower  three  inches 
of  the  rectum  with  a  speculum ;  seize  the  lower  end  of  each  hemorrhoid  in 
turn  with  forceps,  draw  it  downward,  and  with  a  pair  of  strong  scissors  sepa- 
rate it  from  the  underlying  tissues  in  the  long  axis  of  the  bowel  by  cutting 
and  dissecting  from  the  muco-cutaneous  junction  upward  to  the  apex  of 
the  pile,  at  which  point  it  is  tied  with  a  strong  silk  or  catgut  ligature  and 
removed. 

The  Remarks. — The  j)oint  grasped  by  the  ligature  is  an  "isthmus  of 
vessels  and  mucous  membrane."  The  normal  direction  of  the  vessels  ren- 
ders the  separation  easy  and  comparatively  bloodless  unless  the  vessels  be 


UPKIiATlUXS   UN    TllK   ANL'S   AND    RECTUM.  959 

(liviilcd.  Loose  skin  is  snipped  off  and  the  cut  closed  in  witli  fine  catgut 
sutures.  On  numerous  oeciisions  tiie  writer  has  closed  with  fine  catgut  the 
furrows  in  the  mucous  membrane  resulting  from  the  removal  of  the  lia-mor- 
rhoids.  'JMie  growths  having  a  distinctly  columnar  outline  are  the  ones  best 
fitted  for  this  method  of  treatment. 

Whitehead's  Method  {CircuJar  Exci><ion  and  Lujatnre). — Whitehead's 
method  of  oj)eration  consists  in  excision  of  the  pile-bearing  tract.  Place 
the  patient  in  the  lithotomy  position,  using  Clover's  crutch  (Fig.  1303); 
dilate  the  sphincters  fully;  divide  carefully  the  mucous  membrane  around 
the  anal  opening  at  its  junction  with  the  integument;  with  forceps  and 
scissors  expose  the  inner  border  of  the  external  and  the  beginning  of  the 
internal  sphincter;  separate  the  attached  membrane  and  the  associated 
hannorrhoids  from  these  muscles  and  the  subcutaneous  tissue  by  rapid  blunt 
dissection,  and  occasional  division  of  restraining  bands,  and  draw  it  down- 
ward below  the  anus ;  sever  the  mucous  membrane  above  the  haemorrhoids 
in  successive  parts,  and  sew  them  at  once  to  the  corresponding  portions  of 
the  anal  margin  of  the  integument  with  silk;  dust  the  parts  with  iodoform 
and  place  the  patient  in  bed. 

The  Precautions. — Care  should  be  taken  to  divide  the  mucous  membrane 
at  its  ju  net  ion  with  the  integument,  as  failure  in  this  respect  is  often  fol- 
lowed by  annoying  sequels.  The  line  of  union  of  the  divided  mucous  mem- 
brane with  the  cutaneous  border  of  the  anus  should  not  be  taut,  as  a  result- 
ing sejiaration  will  be  succeeded  by  the  annoyances  of  healing  by  granula- 
tion, and  perhaps  later  by  narrowing  of  the  anal  opening. 

The  Comments. — The  primary  incision  is  begun  at  the  most  dependent 
part,  and  follows  closely  the  muco-cutaneous  junction  throughout  the  entire 
circumference  of  the  opening.  The  sphincteric  borders  should  be  carefully 
determined,  and  the  deeper  tissues  cautiously  separated  to  prevent  ha?morrhage. 
The  separation  should  extend  above  the  affected  area — an  inch  or  two — so 
as  to  facilitate  downward  displacement  and  ready  union  of  the  healthy  bor- 
der of  the  mucous  membrane  with  the  integumentary  margin  without  danger 
of  undue  subsequent  traction.  The  bleeding  of  the  operation  is  attendant 
mainly  on  division  of  the  mucous  membrane,  and  although  comparatively 
profuse  is  in  no  wise  dangerous;  it  is  best  controlled  by  fine  catgut  ligatures 
securely  tied.  The  introduction  into  the  anus  of  a  small  plug  made  of  iodo- 
formized  gauze  (Fig.  1171,  e)  wrapped  around  a  catheter  or  rubber  tube, 
for  the  purpose  of  causing  coaptation  of  the  tissues,  and  at  the  same  time 
permitting  the  escape  of  gas,  is  sometimes  practiced  for  a  brief  time  following 
the  operation.  However,  the  presence  of  this  foreign  body  is  commonly  dis- 
agreeable to  the  patient,  and  often  causes  absolute  discomfort  because  of 
its  presence  and  the  sphincteric  contraction  it  sometimes  excites.  The  divi- 
sion and  sewing  of  the  mucous  stump  in  sections  enables  the  operator  to 
maintain  complete  control  of  the  bowel,  and  estimate  properly  the  degree  of 
tension  at  the  line  of  union.  The  removal  from  the  anal  extremity  of  the 
mucous  membrane  endowed  with  special  sensibility  is,  for  physiological  rea- 
sons, regarded  as  objectionable  to  this  plan  of  action.  Severe  cases  can  be 
cured  with  equal  promptness,  less  suffering  and  danger  of  annoying  com- 


900 


OPERATIVE   SURGERY, 


plications  and  sequels  by  simpler  methods.     Pronounced  engorgement  of  the 
veins  without  special  tumor  fornuxtion  can  well  be  treated  by  this  metliod. 

The  Results. — In  the  hands  of  operators  skilled  in  the  method  the 
results  are  reported  as  excellent.  However,  in  those  not  familiar  with  the 
technique,  such  sequels  as  ulcer,  stricture,  neuralgia,  pruritus  ani,  and  even 
incontinence  of  flatus  and  fjeces  are  reported. 

Ligature. — Ligature  and  excision  go  hand  in  hand,  because  points  of 
actual  and  anticipated  bleeding  here  can  be  controlled  quickly  by  ligature, 
and  tissues  strangulated  by  ligature  should  be  removed  by  cutting,  for  obvi- 
ous reasons.  In  connection  with  ligature  of  hai-morrhoids,  it  now  remains 
to  speak  of  treatment  by  submuco-cutaneous  and  transfixion  ligature  of  these 
tumors,  followed  by  excision. 

Pass  suhmuco-cutaneously  a  chromicized-catgut  suture,  seize  with  a 
hook,  lift  up  and  sever  the  ha^morrhoid,  tightening  the  ligature  at  the  time. 
Finally,  tie  securely,  thus  converting  the  hi\3morrhoidal  site  into  a  simple 
incised  wound  with  securely  apposed  borders  (Fig.  1192). 

An  Old  Metliod. — Seize  the  pile  with  forceps  at  the  base,  transfix  it  with 
.a  needle  bearing  a  double  ligature;  interlock  the  ligatures,  tie  the  tissues 
firmly  in  halves,  and  cut  off  the  strangulated  growths.     This  is  a  rapid  and 

safe  method  when  con- 
ducted with  due  aseptic 
regard.  The  loss  of  blood 
is  slight,  and  for  these 
reasons  the  practice  is 
indicated  in  feeble  and 
aged  patients  affected 
with  large  and  well- 
formed  piles. 

The  Remarks.  —  In 
this  method,  as  in  others 
of  like  nature,  the  too 
free  removal  of  mucous 
membrane  is  likely  to  be 
followed  by  narrowing  of 
the  anal  orifice.  The  se- 
quel can  be  prevented  by 
leaving  between  the  respective  ligatures  independent  areas  of  mucous  mem- 
brane. The  contraction  attending  the  cure  will  remedy  the  small,  untied 
hemorrhoids.  If  too  large  for  this  purpose,  they  may  be  punctured  with 
the  heated  points  of  a  Paquelin  cautery  without  causing  objectionable  con- 
traction of  the  mucous  membrane. 

Coates's  Metliod. — Seize  the  pile  with  forceps  and  draw  it  down,  and 
apply  to  the  pedicle  a  long,  narrow  clamp ;  pass  beneath  the  clamp  a  proper 
number  of  sutures  of  fine  catgut ;  excise  the  pile,  loosen  the  clamp,  check 
bleeding,  remove  the  clamp  and  tie  the  sutures  tightly. 

The  Crushing  Method  (Pollock).— The  crushing  method  consists  in  crush- 
ing the  pedicle  of  the  growth  by  an  improvised  instrument  or  one  especially 


Fig.  1192. — Operation  for  the  cure  of  haemorrhoids. 
Submuco-cutaneous  lirature  and  excision. 


OI'KliA'I'IoNS   OX    Till-:    ANUS   AND    Ur^^CTUM. 


001 


Fig.  1193. — Alliiigham's  iiistruiiKTit  for  crushing 
hirinorrlioids. 


constructed  for  ilint  luiriiosc  (l'"i^r.  lllKjj.  TliLs  nictliod  is  not  suitable  for 
uuiversjil  application,  but  rather  for  those  tumors  that  possess  well-defined 
bases.  Tiic  integunu'iit, 
if  it  be  connected  with 
the  tumor,  should  be  in- 
cised, otherwise  great 
pain  will  follow. 

The  Operation. — 
The  patient  is  prepared, 
as  in  the  preceding  in- 
stances ;  the  pile  is 
pulled  between  the  bars 
of  the  instrument  by 
the  aid  of  a  hook  or  a 
volsella,  after  which  the 

screw  is  turned  tightly  against  it.  The  projecting  portion  is  then  cut  off. 
The  instrument  is  retained  in  position  for  half  a  minute  or  so  to  insure 
against  the  danger  of  h;\imorrhage.  While  this  method  may  be  classed 
among  the  satisfactory  ones,  it  possesses  no  superiority  over  the  treatment 
by  ligature,  and,  as  a  rule,  causes  more  pain,  permits  a  less  speedy  recovery, 
and  exposes  the  patient  to  a  greater  danger  of  subsequent  haemorrhage. 

The  Clamp  and  Cautery  Method  (Cusack). — The  method  by  clamp  and 
cautery  is  strongly  advised  by  many  eminent  surgeons,  and  surely  the 
promptness  and  efficiency  of  the  practice  can  be  highly  commended. 

The  Operation. — \yith  the  patient  under  an  anaesthetic,  in  the  lithotomy 
position  and  with  the  sphincter  dilated,  seize  the  tumor  with  the  forceps, 
and  draw  it  from  the  anus  or  expose  it  with  a  speculum  ;  divide  the  cutaneous 
surface,  if  present,  with  blunt-pointed  scissors  or  a  knife ;  apply  the  clamp 
(Fig.  ini,  q)  to  the  base  of  the  tumor  in  the  long  axis  of  the  gut,  including 
the  cutaneous  sulcus  if  present,  and  screw  the  blades  firmly  together;  cut 
away  the  tumor  with  scissors  and  cauterize  the  stump  deliberately  with  red 
heat  (Paquelin  cautery);  loosen  the  clamp,  and,  if  bleeding  occur,  close  it 
and  cauterize  again.  The  tumors  are  thus  treated  one  by  one  until  all  are 
removed. 

The  Remarks. — The  tissues  should  be  slowly  and  thoroughly  charred, 
otherwise  bfemorrhage  will  take  place.  If  the  growths  be  large  the  clamp 
should  not  grasp  the  tissue  quite  down  to  the  anal  junction  for  fear  of  causing 
subsequent  contraction.  However,  in  cases  with  relaxed  sphincter  this  pre- 
caution is  not  of  so  much  importance.  Care  should  be  exercised  not  to 
burn  the  integument,  as  such  injuries  are  very  troublesome. 

The  Results. — This  operation  is  quickly  performed  and  the  results  are 
very  satisfactory.  Caution  is  needed  to  note  the  entire  absence  of  bleeding 
before  the  patient  is  removed  to  bed,  as  much  blood  may  accumulate  in  the 
bowel  without  the  least  escape  from  the  anus. 

Injection. — The  injection  of  carbolic  acid  and  of  astringent  agents,  to- 
gether with  the  application  of  caustics,  are  not  entitled  to  the  dignity  of 
rank   sometimes   accorded    to   them.     The    occasional  severe  inflammatory 


962  OPERATIVE   SURGERY. 

reaction,  often  followed  by  abscesses  and  gangrene,  and  the  fickleness 
of  cure  unfit  these  measures  for  trustworthy  station  with  the  methods  of 
cure. 

The  General  Remarks. — In  instances  of  excision  or  ligature  of  haemor- 
rhoids having  a  cutaneous  surface,  the  cutaneous  surface  should  be  divided 
in  the  line  of  the  jjroposed  constriction  with  a  knife  or  blunt-pointed  scis- 
sors— the  latter  being  the  better — before  tying  is  attempted.  If  this  be  not 
done,  the  degree  of  pain  incident  to  tying  in  of  the  skin  will  be  severe  and 
quite  persistent. 

In  those  cases  characterized  by  a  rosette  arrangement  of  the  hemorrhoids 
'completely  around  the  bowel  within  the  anus,  the  circular  mass  should  be 
divided  into  five  or  six  segments  and  separately  ligatured.  The  segmenta- 
tion can  be  executed  by  means  of  a  grooved  director  through  a  small  incision 
in  the  mucous  membrane  made  at  either  side  of  the  pile,  or  by  direct  incision, 
or  transfixion  with  a  needle  armed  with  a  ligature.  When  properly  isolated 
the  segments  are  tied  separately  with  silk  or  chromicized  catgut. 

The  transfixion  and  tying  of  hfemorrhoidal  growths  is  regarded  by  many 
as  improper  practice.  It  is  claimed  that  a  needless  amount  of  tissue  is 
included,  that  vessels  are  punctured  and  infection  invited  by  the  practice. 
The  writer  is  not  disposed  to  regard  the  measure  as  objectionable  in  isolated 
tumors  with  thorough  asepsis,  and  has  practiced  it  not  infrequently,  and  thus 
far  without  an  unfavorable  result. 

General  anaesthesia  meets  the  requirements  more  completely  than  local ; 
the  latter,  however,  is  sufficient  in  the  simplest  cases.  Catgut  ligatures  are 
liable  to  slip  and  be  followed  by  haemorrhage ;  silk  ones  are  safer,  but  more 
likely  to  be  annoying  because  non-absorbable.  ^arrowing  of  the  anus  rarely 
follows  in  ligature  or  cautery  except  the  integument  be  encroached  upon. 
Dependent  incisions  should  be  made  first,  to  avoid  obscurement  of  the  line 
of  incision  by  blood.  The  strength  of  ligatures  should  be  tested  before 
applying  them  to  the  haemorrhoids.  Temporary  retention  of  urine  is  a  fre- 
quent sequel  of  operation  for  haemorrhoids,  and  the  occurrence  should  be 
anticipated  and  provided  for  in  each  instance. 

The  choice  of  operation  is  largely  a  matter  of  personal  experience.  The 
author  employs  excision  and  ligature  after  the  manner  of  Allingham,  and 
ligature  alone  by  transfixion  more  frequently  than  he  does  the  other  methods, 
and  thus  far  without  regret.  The  excision  of  the  pile-bearing  tract  is  a 
logical  procedure  and  in  extensive  involvement  at  the  anus  is  widely  prac- 
ticed. Mr.  Whitehead,  the  designer,  and  others  have  performed  it  on  numer- 
ous occasions  with  excellent  primary  and  final  success.  The  clamp  and  cau- 
tery plan  is  a  good  one,  especially  in  well-defined  growths,  and  is  ably  advo- 
cated by  Kelsey  of  this  city. 

The  after-treatment  is  simple  and  consists  of  the  application  to  the  anus 
of  iodoform;  a  cotton  pad  held  in  place  with  a  T-bandage  ;  opium  for  pain 
and  spasm.  The  patient  should  be  kept  quiet  in  bed  for  four  or  five  days 
and  cleanliness  of  the  parts  secured.  About  this  time  obtain  a  good  move- 
ment with  oil  supplemented  with  a  simple  enema.  The  preliminary  diet 
should  be  devoid  of  solid  food. 


OPKKA'IMON'S   ()X    TllK    AXIS    AND    IcKCTlM.  903 

Tlir  f,'csi(I/s. — 'riic  (lentil  rate  in  St.  Mark'.s  Ilosjiital  "from  all  causes  in 
()l)ci'at  ions  (111  iMteiiial  li;i'iii(in'li<H(Ls  hy  ligature  diiriiii;  a  space  of  inoi'c  than 
forty  years  is  jiisL  1  in  (ilo"  (Alliiii^diaru).  AlliiKjliain  reports  over  1,<J()0 
cuscs  of  his  own  with  hut  a  single  death.  Other  siirfj^eons  of  extensive  expe- 
rience make  similar  favorable  rejiorts.  Where  2)roper]y  ])erform('(l  the  alTcc- 
tion  seldojn  returns  and  then  only  after  many  years. 

Operations  on  the  Rectum. — The  protected  position  of  the  rectum  exempts 
it  from  many  of  the  common  injuries  to  whicli  the  abdominal  contents  are 
exposed.  However,  disease  of  this  bowel  is  sufiiciently  frequent  to  demand 
its  careful  consideration. 

Tlie  A7into)nir((l  Poiiifs. — The  rectum  is  about  eight  inches  in  length, 
varying  according  to  the  height  of  the  individual.  As  usually  described  it 
extends  from  the  left  sacro-iliac  synchondrosis  to  the  anus.  It  has  three 
portions  and  three  curves.  Tlie  first  portion  extends  from  the  synchondrosis 
to  the  middle  of  the  third  sacral  vertebra.  It  is  about  three  and  a  half 
inches  in  length  and  surrounded  almost  entirely  with  peritonaeum.  Poste- 
riorly it  is  in  relation  with  the  pyriformis  muscle,  sacral  plexus,  and  branches 
of  the  internal  iliac  artery  on  the  left  side,  which  lie  between  the  gut  and 
the  sacrum,  and  sacro-iliac  junction.  The  prerectal  pouch,  containing  small 
intestines,  lies  in  front.  It  is  proper  to  say  at  this  time  that  the  first  portion, 
as  ordinarily  described,  is  regarded  by  Treves  as  the  continuation  of  the 
sigmoid  flexure.  According  to  this  the  rectum  begins  at  the  third  sacral 
vertebra,  or  where  the  mesocolon  disapi)ears.  The  middle  portion  is  about 
three  inches  in  length.  It  begins  at  the  ending  of  the  first  j^ortion  and 
terminates  at  the  apex  of  the  prostate,  an  inch  below  the  level  of  the  tip  of 
the  coccyx.  It  is  covered  by  peritonaeum  in  front  at  its  upper  part,  which 
is  reflected  from  its  anterior  surface  to  the  bladder  in  the  male  about  an 
inch  above  the  base  of  the  prostate.  It  rests  on  the  sacrum  and  coccyx 
behind,  and  is  in  contact  with  the  trigone  of  the  bladder,  prostate,  semi- 
nal vesicles,  vasa  deferentia  in  the  male,  and  the  posterior  wall  of  the 
vagina  in  the  female,  in  front.  The  loioer  portion  is  about  an  inch  and 
a  half  in  length,  and  extends  from  the  apex  of  the  prostate  to  the  anus. 
In  front  a  wedge-shaped  mass  of  tissue  intervenes  ])etween  it  and  the  bulb- 
ous portion  of  the  urethra  in  the  male,  and  similarly  between  it  and  tlie 
vagina  in  the  female. 

T/te  Three  Curves. —  The  first  curve,  an  inch  and  a  half  in  length,  extends 
from  the  anus  to  near  the  prostate,  and  is  directed  upward  and  forward — a 
fact  which  should  be  remembered  in  the  introduction  of  instruments.  T/ie 
secoid  curve  follows  the  curve  of  the  sacrum,  and  is  about  three  inches  in 
length ;  the  greater  portion  of  this  curve  is  covered  with  peritonaeum,  which 
is  reflected  upon  it  at  a  level  of  about  two  and  a  half  inches  above  the  anus 
in  front,  and  about  five  inches  behind,  when  the  bladder  and  rectum  are 
empty;  if  the  latter  are  filled,  the  distance  is  increased  about  an  inch.  The 
anterior  surface  of  the  lower  part  of  this  curve  is  intimately  associated 
with  the  base  of  the  bladder,  vesiculje  seminales,  and  prostate  body  in  the 
male,  and  the  posterior  wall  of  the  vagina  in  the  female.  The  third  curve 
extends  from  the  middle  of  the  third  piece  of  the  sacrum  to  the  left  sacro- 
67 


1)64 


OPERATIVE  SURGERY. 


iliac  synchondrosis.  This  curve  is  almost  entirely  surrounded  by  serous 
membrane.  The  arteries  having  surgical  associations  with  the  rectum  are 
the  superior,  middle,  and  inferior  hivmorrhoidal  arteries.     The  first  is  the 


Fig.  1194. — Instruments  employed  in  examination  of  the  lower  bowel. 

fe  holder,     h.  Applicator,     c.  Curette,     d.  Anal  dilator 
■ted  lengths,     h.  Sigmoidoscope.    Various  forms  of  rectal 
be  employed  in  examination  of  the  lower  part  of  the  rectum. 


a.   Sponge  holder,     h.  Applicator,     c.  Curette,     d.  Anal  dilator,     e,  /.  g.    Proctoscopes, 
assorted  lengths,     h.  Sigmoidoscope.    Various  forms  of  rectal  specula  (page  953)  may 


OI'KWATIONS   ON    TIIH    ANl'S    AND    lIlOC'irM. 


905 


most  iiuportunt ;  it  runs  between  the  rec-tiini  iuul  tlie  siieriun,  ii  little  to  the 
left  of  the  niediiui  line,  to  within  tiliout  four  or  four  und  a  half  inches 
of  the  anus,  a  fact  that,  should  i)e  i-eniemhercd  in  making  high  incisions  of 
the  rectum. 

The  arteries  in  the  uiipcr  half  picn'c  the  muscular  coat,  forming  a  cap- 
illary network  in  the  submucous  tissues  ;  in  the  lower  half  the  vessels  take 
a  longitudinal  course  to  the  anus  and  anastomose  there  through  transverse 
branches.  This  longitudinal  arrangement  explains  the  reason  why  longi- 
tudinal incisions  of  the  rectum  bleed  so  little  and  transverse  ones  so  freely. 
The  veins  follow  the  course  of  the  arteries,  forming  a  plexus  at  the  lower 
part  of  the  bowel  which  empties  its  blood  into  the  internal  iliac  and  inferior 
mesenteric  veins.  The  relations  of  the  tissues  to  the  vessels  and  direction 
of  the  veins  at  the  lower  two  or  three  inches  of  the  bowel  explain  the  loca- 
tion of  haemorrhoids  and  their  relation  to  the  arteries  and  submucous  tissues. 
The  lymphatic  channels  connect  with  the  glands  of  the  sacral  and  lumbar 
regions.  Sphincteric  contraction  is  manifest  throughout  the  lower  inch  of 
the  bowel.  An  inch  and  a  half  above  the  anus  the  free  border  of  the  levator 
ani  muscle  can  be  felt  posteriorly. 

Rectal  Examination. — Two  methods  of  direct  rectal  examination  are 
practiced:  1,  by  the  fingers,  specula  (Fig.  1194),  light,  etc.,  aided  by  the 
position  of  the  patient;  2,  by  the  introduction  of  the  entire  hand. 


Fio.  1195. — The  exaggerated  litliotomy  position  for  examination  of  the  anus  and  rectum. 

In  the  former  method,  cleanse  the  bowel  thoroughly  and  empty  the  blad- 
der ;  place  the  patient  in  the  latero-prone  or  the  exaggerated  lithotomy  or 
knee-chest  position,  depending  on  the  scope  of  the  examination.  If  only 
digital  examination  be  intended  the  first  will  suffice.     Oil  the  index  finger 


966  OPERATIVE   SUIKJEllY. 

and  introduce  it  gently  with  a  semirotary  motion,  allowing  the  remaining 
fingers  to  remain  between  the  nates.  By  this  method  the  lower  four  or  five 
inches  of  the  gut  can  be  palpated  with  the  use  of  moderate  force.  The 
extent  of  the  examination  is  increased  somewhat  if  the  patient  bear  down. 
The  introduction  of  the  middle  finger  along  with  the  index  adds  still  more 
to  the  extent  of  the  examination.  An  educated  touch  will  enable  the  surgeon 
to  comprehend  with  astonishing  exactness  the  physical  state  of  the  rectum 
and  its  surrounding  structures.  The  use  of  a  speculum,  aided  by  a  good 
light,  will  permit  observation  of  the  lower  half  of  the  gut.  However,  to 
secure  a  more  thorough  and  extended  inspection,  place  the  patient  in  the 
exaggerated  lithotomy  position  (Fig.  1195) ;  then  draw  backward  the  posterior 
wall  of  the  rectum  with  a  Sims's  speculum ;  press  the  anterior  wall  forward 
with  a  uterine  or  a  special  depressor,  or  the  handle  of  a  tablespoon,  when, 
with  the  aid  of  a  good  light — electric  or  otherwise  (Fig.  103) — the  lower 
four  or  five  inches  of  the  rectum  can  be  quite  well  seen.  The  use  of  a  small, 
soft  sponge  on  a  sponge  holder  will  aid  much  by  smoothing  out  the  folds  of 
the  bowel  and  wiping  its  surface  clean.  Under  the  influence  of  a  strong 
light  and  the  bowel  well  distended  with  air,  three  valves,  and  sometimes  four, 
are  observed.  The  largest  and  most  constant  is  usually  connected  with  the 
anterior  wall  at  a  point  opposite  the  neck  of  the  bladder  and  about  three 
inches  from  the  anus.  The  second  largest  is  attached  to  the  right  wall  of 
the  bowel  near  to  the  upper  end  of  the  rectum.  The  third  midway  between 
the  preceding  at  the  left  wall  of  the  gut.  When  present,  the  fourth  arises 
toward  the  left  from  the  posterior  wall  and  is  about  an  inch  above  the  anus. 
The  fact  that  they  may  be  mistaken  for  evidence  of  disease  and  often  do 
become  the  seat  of  diseased  action  prompts  the  giving  of  this  somewhat 
detailed  description.  The  bowel  can  be  examined  yet  higher  by  placing  the 
patient  in  the  knee-chest  position  (Fig.  1190)  and  employing  the  long  proc- 
toscope (Fig.  119-i, ^)  or  the  sigmoidoscope  (h),  supplemented  by  a  strong 
light  and  a  head  mirror. 

2.  The  Introduction  of  tlie  Entire  Hand. — The  introduction  of  the  entire 
hand  must  be  done  with  great  caution  in  order  not  to  lacerate  the  bowel  or 
the  peritonaeum  enveloping  it.  For  this  purpose  the  patient  is  placed  upon 
the  back,  anesthetized,  bladder  emptied,  and  the  services  of  a  person  with  a 
small  hand,  not  exceeding  eight  inches  in  circumference.,  are  enlisted.  The 
hand  is  well  oiled,  and  given  a  conical  form  by  applying  the  thumb  to  the 
palmar  surface  of  the  approximated  fingers.  The  tips  of  the  fingers  are  then 
carefully  inserted  by  a  semirotary  motion,  which  is  slowly  continued  until 
the  whole  hand  enters  the  bowel.  After  the  entrance  of  the  hand,  the  fingers 
are  moved  in  various  directions  to  ascertain  the  caliber  and  condition  of  the 
gut,  and,  at  the  same  time,  to  favor  the  circulation  of  the  imprisoned  hand. 

If  the  hand  meet  a  narrowing  of  the  bowel  at  a  distance  of  three  or  four 
inches  above  the  anus,  but  little  force  should  be  used,  as  the  peritona?um, 
which  is  connected  with  the  gut  in  this  situation  and  is  the  probable  cause 
of  the  narrowing,  may  be  ruptured.  If  the  hand  be  unusually  small,  it  not 
infrequently  happens  that  the  sigmoid  flexure  may  be  passed,  the  descending 
colon  entered,  and  the  kidneys,  uterus,  and  great  vessels,  etc.,  be  intelligently 


OI'IIKATIONS   ON    Till';    AXIS    AND    KIlC'I'l'M. 


im 


examined.  It  is,  liowever,  oxtiviuoly  fali'^uiii';  to  tlie  cxainiuer;  still,  tlie 
discomfort  experienced  should  not  lead  the  surgeon  to  relax  in  the  least  the 
degree  ol'  caution  necessary  to  the  safety  of  the  patient. 


Fic.  1196. — High  examination  of  the  bowel,  patient  in  knee-chest  position. 

Ischio-rectal  Abscess, — Abscess  of  the  ischio-rectal  fossa  is  of  compara- 
tively common  occurrence.  Its  chief  surgical  importance  relates  to  fistula 
in  ano.  The  abscess  may  be  caused  by  perforation  from  within  the  bowel, 
and  therefore  when  incised  from  without  leads  to  prompt  development  of  a 
complete  fistula  in  ano.  On  the  other  hand,  if  the  abscess  have  no  internal 
communication  at  the  outset,  one  may  soon  develop  from  localized  sloughing 
of  the  intestinal  wall  from  suppuration. 

The  Anatomical  Points. — The  ischio-rectal  fossa  is  located  between  the 
end  of  the  rectum  and  the  tuber  ischium  at  each  side  (Fig.  1198).  It  is 
triangular  in  shape,  the  base  corresponding  to  the  perina?um  and  the  apex 
to  the  point  of  origin  of  the  anal  {g)  from  the  obturator  fascia  ( /").  The 
ischio-rectal  fossa  is  about  an  inch  in  width  at  the  base  and  two  inches  in 
depth,  being  deeper  behind  than  in  front.  It  is  limited  in  front  by  the 
Junction  of  the  deep  and  superficial  perineal  fascifp,  behind  by  the  gluteus 
maximus  muscle  and  the  great  sacro-sciatic  ligament.  It  is  filled  with  adi- 
pose tissue,  through  which  run  h^Bmorrhoidal  vessels  and  nerves  and  branches 
of  the  internal  pudic,  sometimes  of  large  size.  Also  a  branch  of  the  fourth 
sacral  nerve  is  found  at  the  back  part  of  the  fossa,  and  the  superficial  perineal 
vessels  and  nerves  at  the  front. 


968 


OPERATIVE  SURGERY. 


Fig.  1107. — Instruments  employed  in  operations  on  the  rectum. 

Blunt  flat  retractor,  h.  Curved  and  straight  blunt-pointed  bistouries,  c.  Long 
straight  and  curved  scissors,  d.  Tongue  forceps  for  grasping  rectum,  e.  Sponge 
holder.  /.  Needle  holder,  g.  Steel  sound,  h.  Forceps  for  grasping  bowel,  i.  Scoop. 
j.  Duckbill  speculum,  k.  Fenestrated  speculum.  I.  Sponge  with  string  attachment 
for  closing  bowel  above,  m.  Long  and  short  needles,  n.  Aseptic  pad  anehore<l. 
0.  Chromicized  catgut  and  silkworm  gut.  p.  Mallet,  q.  Chisel,  r.  Black  silk. 
Scalpels,  ligatures,  wipers,  forcipressure,  and  blunt  dissector  are  required. 


OPERATIONS  ON  THE   ANUS   AND    RECTUM. 


969 


Tlie  Operation. — Thorouglily  cleanse  and  shave  the  perinanim ;  employ 
local  or  general  an;v.'stliesia  as  circumstances  demand.  The  situation,  direc- 
tion, and  extent  of  the  liberating  incisions  will  depend  on  the  location  and 
extent  of  the  abscess.  If  the  abscess  be  superficial,  either  antero-posterior 
or  radiating  incisions  are  suitable.  If  deep,  the  radiating  should  be  em- 
ployed, carefully  avoiding  the  sphincter  ani  and  the  internal  i)udic  vessels. 
Circumscribing  incisions  should  be  avoided.  If  abscess  be  in  front  of  the 
rectum  a  transverse  perineal  incision  in  the  male  and  vaginal  incision  in  the 
female  may  be  required.  If  behind,  or  at  the  side  of  the  bowel  high  up,  a 
posterior  median  incision  may  be  needed.     In  all  instances  the  finger  should 


Fig.  1198. — The  ischio-rectal  spaces  and  contiguous  anatomy,  a.  Iliac  fascia,  h.  Ante- 
rior crural  nerve,  c.  Iliao  vessels,  d.  Brim  of  pelvis,  e.  Recto-vesical  fascia.  /. 
Obturator  fascia,  g.  Anal  fascia,  h.  Internal  pudic  vessels  and  nerve.  *  Ischio- 
rectal fossje.     f  Anterior  superior  spine  of  ilium. 

be  carried  into  the  opening  and  search  made  for  channels  and  pockets, 
exploring  freely  in  every  direction.  A  single  cavity  may  be  formed  if  prac- 
ticable;  if  not,  the  side  pockets  should  be  drained  by  suitably. located  inci- 
sions. Thorough  cleansing  and  light  packing  with  gauze  should  follow, 
being  repeated  during  the  healing  process  as  frequently  as  cleanliness  and 
good  drainage  require. 

The  Remarhs. — Abscess  may  develop  between  the  recto-vesical  and  anal 
fascia  (/;),  and  at  either  side  between  the  levator  ani  muscle  and  the  base  of 
the  bladder,  or  it  may  extend  from  the  ischio-rectal  fossa  to  these  situations. 
An  ischio-rectal  abscess  may  be  of  limited  size,  located  at  any  part  of  the 
fossa  or  invade  the  entire  space.  The  devious  curves  pursued  by  the  sup- 
puration, and  the  greater  need  of  care  to  secure  good  drainage  call  for  the 


970 


OPERATIVE  SURGERY. 


exercise  of  patience  in  the  detection  and  drainage  of  the  suppurating  recesses. 
The  sooner  and  freer  the  openings  are  made  the  less  will  be  tlie  extent  of 
the  invasion  and  the  prompter  the  recovery.  If  the  abscess  has  come  from 
internal  perforation  the  fact  should  be  determined  at  once,  and  time  and 
annoyance  saved  by  immediate  treatment  of  the  fistulous  opening. 

Imperforate  Rectum  (Figs.  1109  and  1200). — The  occluding  tissue  in 
imperforate  rectum  varies  in  thickness,  and  is  nsually  situated  within  half 
an  inch  of  a  normal  anus.  If  the  septum  be  thin,  it  will  be  influenced  by 
the  emotions  of  the  child  and  depressed  by  the  superimposed  faical  accumn- 
lations ;  also  evidences  of  fluctuation  may  be  present.  At  all  events,  the 
use  of  an  aspii-ating  needle  will  aid  much  in  settling  the  question  of  thick- 
ness. Intraperitoneal  exploration  by 
either  the  sacral  or  jierineal  route  for 
diagnosis  is  commendable  practice. 
The  presence  of  an  anal  depression 
is   not   evidence  of   a  thin    septum ; 


Fig.  1199.  Fio.  1200. 

Fig.  1199. — Imperforate  rectum,  with  rudiraentarv  anus. 
Fig.  1200.— Imperforate  rectum,  anatomical  relations,     a.   Upper  rectum, 
c.  End  of  pouch,     e.  Septum,     d.  Lower  rectum. 


h.   Bladder. 


on  the  contrary,  the  reverse  may  be  noted.  The  presence  of  a  normal  anus 
may  mislead  one  as  to  the  trne  nature  of  the  case,  therefore,  a  careful  and 
extended  examination  should  always  be  practiced.  In  some  instances  the 
rectal  pouch  is  high  in  the  pelvis  or  abdomen,  when  the  interval  between  it 
and  the  perinaeum  is  a  distinct  fibrous  cord  (Fig.  1167).  Not  infrequently 
the  rectum  communicates  with  the  bladder  (Fig.  1201),  sometimes  with  the 
urethra  (Fig.  1202),  and  even  the  glans  penis  (Fig.  1203),  conditions  which 
are  determined  by  the  character  of  the  urine.  Female  children  suffer  from 
congenital  abnormal  outlets  of  the  rectum  and  anal  communications  (Figs. 
1204  and  1205).  Prompt  diagnosis  and  prompt  treatment  are  essential  to 
success  in  these  cases  in  all  instances  of  complete  occlusion.     In  incomplete 


UPKUATIONS   ()X    'I'lIK    AXIS    AND    [{KC'I'IM. 


971 


occlusion,  witli  (li-i!)l)liiii:  <'f  intestiiuil  contents,  notliin<^  can  bo  gained  by 
delay,  exeepi  |>rili;ips  in  iliose  cavses  with  a  vesical  or  urethral  opening.  It 
should   be   recalU'il    that  tlie  operations  are  addressed  in  every  instance  to 


Fig.  1201.— Absence  of  anus  and  lower  part     Fig.  1202. — Absence  of  anus  and  lower  part 
of  rectum,  rectum  opening  into  bladder.  of  rectum,  rectum  opening  into  urethra. 

infantile  dimensions.     The  diameters  between  the  important  bony  promi- 
nences which  serve  as  guides  are  scarcely  more  than  an  inch  in  any  instance. 


Fig.  1203.— Absence  of  anus,  lower  part  of      Fig.  1204.— Absence  of  anus,  rectum  open- 
rectum  communicating  with  glans  penis.  ing  into  vagina. 

The  primanj  indication  of  treatment  is  to  establish  an  artificial  anus,  pref- 
erably in  the  inguinal  region. 


972 


OPERATIVE   SURGERY. 


TJie  Operation. — With  the  patient  in  the  exaggerated  lithotomy  position 
(Fig.  1195),  introduce  the  finger  into  the  rectum,  note  the  seat  and  extent 
of  the  septum,  and  make  incisions  into  it,  radiating  from  the  center ;  evacu- 
ate the  contents  of  the  gut,  trim  off  the  flaps,  and  maintain  the  o})euing  by 
the  occasional  introduction  of  a  well-oiled  bougie.  8ometimes  the  occlu- 
sion is  so  thick  as  to  raise  the  question  of  the  presence  or  absence  of  the  gut 
above.  The  sigmoid  flexure  may  terminate  in  a  blind  point,  while  the  rec- 
tum below  is  marked  by  an  impervious  cord  (Fig.  IIGT).  An  attempt  should 
always  be  made  to  find  the  blind  extremity,  which  is  practiced  by  intro- 
ducing a  sound  into  the  bladder  and 
carefully  seeking,  by  aid  of  the  scissors 
and  finger,  for  the  cul-de-sac  above. 
In  the  search  the  established  relation 
which  the  rectum  bears  to  the  curve 
of  the  sacrum  must  be  carefully  re- 
garded, and  the  fibrous  trace  of  the 
rectum  sought  after  and  followed.  If 
the  abdomen  of  the  patient  be  pressed 
upon,  an  existing  tumor  above  will 
be  made  more  distinct  and  tense.  If 
the  cul-de-sac  be  found,  the  diagnosis 
should  be  still  further  strengthened 
by  exploring  the  tumor  wdth  a  hypo- 
dermatic syringe  or  a  small  aspirating 
needle  carried  into  its  posterior  aspect. 
The  release  of  the  faecal  accumulation 
is  often  attained  quite  readily  by  this 
method.  However,  the  primary  suc- 
cess often  is  quite  misleading,  since  the  time,  trouble,  and  pain  necessarily 
attendant  on  the  persistent  employment  of  bougies  to  maintain  patency  of 
the  opening  becomes  so  much  of  an  infliction,  as  soon  to  be  unbearable,  and 
death  ensues  in  a  large  number  of  cases.  This  plan  can  not  be  commended. 
If  possible,  the  blind  extremity  of  the  gut  is  drawn  carefully  downward 
toward  the  external  opening,  and  held  in  this  position  by  forceps  or  by  a  loop 
of  thread  passed  through  its  apex  while  it  is  opened  carefully,  the  incision 
being  guided  by  the  exploring  needle,  which  is  allowed  to  remain  for  that 
purpose.  After  the  contents  are  evacuated  and  the  parts  thoroughly 
cleansed,  a  sponge  with  a  string  (Fig.  1197  /)  attached  to  it  is  pushed  up 
into  the  bowel  to  prevent  any  further  escape  of  fjecal  matter,  while  the 
extremity  of  the  bowel  is  sewed  to  the  surface  below  (proctoplasty). 

Proctoplasty. — Proctoplasty  consists  in  drawing  down  the  rectal  pouch, 
and  uniting  its  borders  to  the  normally  located  anus,  or,  in  the  event  of  the 
presence  of  a  rectal  pouch  too  short  to  be  thus  treated,  the  establishment  of 
a  new  anus  at  the  tip  of  the  coccyx,  or,  as  in  sacral  proctectomy,  still  higher 
up  in  this  region,  if  need  be,  after  removal  of  the  coccyx  or  lower  portion  of 
the  sacrum  (page  990).  When  this  step  is  impracticable,  or  the  extremity 
of  the  bowel  can  not  be  found,  colostomy  (page  G75)  should  be  performed. 


Fig.  1205. — Imperforate  reetuin,  lower  por- 
tion of  rectum  communicating  with 
vagina. 


OPERATIONS   ON   THE   ANUS   AND   liKCTUM.  973 

As   tlio   iH'i^tuiu  sometimes  communicates  witli   the   bladder,  and  even   the 
gluiis  [iciiis  or  va<>ina,  various  plans  of  operation  are  practiced. 

Rizzoli's  method  (recto-vaginal)  of  treatment  of  this  class  of  cases  is 
practiced  as  follows:  Place  the  patient  in  the  exaggerated  (Fig.  1105)  lithot- 
omy position;  introduce  into  the  rectum  through  the  abnormal  vaginal  ori- 
fice a  sharply  curved  vesical  sound  (Fig.  I'i04);  make  an  incision  in  the 
median  line  from  the  margin  of  the  abnornud  anal  orifice  in  the  vagina  down 
to  the  rectum  aiul  to  the  tip  of  the  coccyx;  expose  the  rectum  cautiously 
as  far  as  possible  by  the  median  incision  ;  dissect  out  the  vaginal  anus  ;  sepa- 
rate the  attached  intermediate  portions  of  the  rectum,  and  transplant  the 
vaginal  anus  and  its  connections  to  the  posterior  angle  of  the  wound,  as 
near  to  the  coccyx  as  possible,  without  much  traction ;  stitch  the  margin  of 
the  transplanted  anus  to  the  posterior  angle  of  the  wound ;  unite  the  borders 
of  the  vaginal  wound  with  each  other,  and,  lastly,  also  those  of  the  peri- 
n;eum.  Dress  the  wound  in  the  usual  manner  and  maintain  cleanliness. 
In  the  other  forms  of  this  variety  of  infliction  the  bowel  should  be  sought 
for,  drawn  down,  and  the  abnormal  communication  located  and  closed  by 
sutures,  if  possible,  and  the  end  of  the  bowel  stitched  to  the  cutaneous  bor- 
der of  the  wound.  This  plan  of  action  is  especially  serviceable  in  the 
involvement  of  the  penis,  particularly  if  supplemented  with  slitting  up  of 
the  sinus.  In  the  vesical  variety,  however,  the  outcome  is  dubious  because 
of  the  higher  situation  and  larger  size  of  the  opening,  and  the  greater  difK- 
culty  of  securing  suitable  adjustment  of  the  rectal  wall.  In  the  latter  cases 
the  bladder  should  be  evacuated  frequently  to  prevent  distention  during  the 
healing  process.  Colostomy  may  be  the  only  measure  of  substantial  relief  in 
bad  vesical  cases. 

The  Precautions. — The  narrowness  of  the  compass  of  the  field  of  opera- 
tion should  be  kept  constantly  in  view  to  avoid  the  ill  effects  of  a  too  vigor- 
ous or  extended  dissection.  The  use  of  trocars  in  search  of  the  blind  pouch 
is  uncertain  and  often  hazardous,  since  there  is  no  definite  assurance  as  to 
its  size,  situation,  and  relation  to  contiguous  peritoneal  surfaces ;  careful  dis- 
section with  scissors,  etc.,  is  the  safer  and  equally  serviceable.  The  estab- 
lishment of  a  fistulous  opening  at  any  point  whatsoever,  in  the  presence  of 
the  ability  to  create  a  rectum  with  a  proper  lining  (proctoplasty),  should  not 
be  entertained  except  as  a  brief  ameliorative  measure. 

The  Results. — The  final  results  are  not  encouraging  except  in  simple 
cases,  such  as  those  with  thin  septi  and  good  reparative  processes.  The  out- 
come in  the  various  operative  measures  is  succinctly  stated  by  Cripjjs  in  a 
tabulated  statement  of  a  hundred  cases  : 

Colon  opened  into  the  groin 16  cases ;         11  died. 

Colon  opened  into  the  loin 3     "  'Z     " 

Puncture  with  trocar 17     "  U     " 

Coccyx  resected 8     "  5 

Perineal  dissection  or  incision 39     "  14     " 

Complication  with  vagina 1-1     "  1     " 

Miscellaneous 3     "  3 

100     "  50     " 


974  OPERATIVE  SURGERY. 

Twenty-eight  per  cent  of  these  cases  died  of  peritonitis,  20  per  cent 
directly,  and  3S  per  cent  indirectly  from  failure  of  relief. 

Anders's  Series  of  100  Cases. 

Colon  opened  into  the  groin 8  cases ;  4  died. 

Colon  opened  into  the  loin 3     "  2  " 

Littre's  operation  (page  GT5) 10     "  5  " 

Puncture  Avith  trocar 4     "  2  " 

Incision 'i  <  y 

Proctoplasty  (dissection) 44     "  13  " 

Xou-operable 3     "  1 

Miscellaneous _1     "  _0  " 

100     "  36  " 

Prolapsus  Recti. — The  natural  looseness  of  the  submucous  connective 
tissues,  coupled  with  straining  during  defecation,  predispose  to  prolapse  of 
the  rectum.  Two  varieties  of  prolapse  are  commonly  recognized,  the  par- 
tial and  complete.  In  the  former  only  the  mucous  membrane  extrudes,  and 
the  prolapse  is  usually  but  an  inch  or  two  in  length  and  limited  to  the  anus 
(Fig.  1206)  (prolapsus  ani),  and  involving  sometimes  the  muscular  tissue  but 
not  the  serous  covering.  In  the  complete  variety  all  the  coats  of  the  rectum 
and  its  peritoneal  covering  are  involved,  attended  not  infrequently  with  the 
descent  of  loops  of  intestine,  uterine  appendages,  etc.  (Figs.  1207  and  1208). 
Much  discomfort  and  not  a  little  suffering  attends  the  partial  variety  ;  excru- 
ciating distress  is  the  characteristic  feature  of  the  complete. 

The  Treatment  of  Partial  Prolajjse.—Kn  efiEort  should  be  made  to  re- 
move the  causes  of  the  prolapse,  when,  with  proper  regulation  of  the  diet 
and  bowels,  local  soothing  applications,  and  rest  in  bed,  with  the  pelvis  ele- 
vated for  a  time,  a  cure  may  be  effected.  At  all  events,  much  indeed  will 
be  added  to  the  final  outcome  of  operative  procedure.  The  aims  in  the  oper- 
ative cure  of  this  variety  are,  1,  the  production  of  adhesions  of  the  mucous 
membrane  to  the  underlying  tissues;  2,  the  narrowing  of  the  anal  orifice  by 

increasing  the  sphincteric  tone,  and  other- 
wise diminishing  the  anal  caliber.     The 
^         ^^"^""^^  adhesions  may  be  established  by  clamping 

and  destroying  in  the  long  axis  of  the 
bowel  isolated  portions  of  the  mucous 
membrane,   or  by  removing  similar  por- 


r^^  \  '        tions  of  it  by  the  ligature  or  the  galvano- 

■^»''^  '     §       cautery.     If  ha-morrhoids  be  present,  they 

/       should  be  ligatured  or  treated  with  clamp 

and  cautery,  as  these  measures  alone  will 

c^,,, .,  -^      ~  ~^^^^    '  often  effect  a  cure.     The  application  of 

Fig.  1206.— Prolapsus  ani.  Paquelin's   cautery,   longitudinally  or   at 

isolated  points,  to  the  prolapsed  part,  after 
its  return,  is  an  excellent  method  of  procedure,  and,  when  combined  with 
rest  in  the  horizontal  position  and  the  production  of  fluid  evacuations,  will 
often  effect  a  speedy  and  satisfactory  cure,  especially  in  the  young. 


OI'KKATIOXS   OX   TIIK    ANTS    AND    IMK  "IT  M. 


975 


The  Cauterization  Method  (\aii  liiucn). — AiuL-silieLizu  mnl  place  tliu 
patient  in  the  knee-elbow  or  kuee-breast  position  (Fig.  1U8G) ;  reduce  the 
prolapse  and  expose  tlie  parts  with  Sims's  speculum.  Tlien,  with  the 
])oint  of  a  cautery  (Fil,^  K'-)  at  a  dull-red  heat,  make  four  or  live  longi- 
tudinal sti'ipes  about  tlirt'c  inrlu's  in  length  at  erpial  intei'vals  aj)art,  ter- 
minating externally  at  tiie  Ijorder  oi'  the  true  skin.  'J'he  number,  size, 
ajul  ilepth  of  the  eschars  will  depend  on  the  age  of  the  patient  and  the 
severity  of  the  case.  In  the  infant,  two  or  three,  a  line  or  two  in  width,  may 
l)e  sufficient.  The  older  the  patient 
and  the  severer  the  case,  the  deeper 
should  he  the  eschars. 


Fig.  1207. — PrKlap^e  ui  lectum,  with 
invagination. 


Fig.  1208. — Complete  prolapse  of  rectum. 
a.  Rectum,  b.  Bladder,  c.  Uterus. 
d.  Pubes.    e.  Peritonaeum.    /.  Vagina. 


The  Comments. — The  eschar  shotild  be  deepened  as  the  sidiincter  is 
approached  if  the  prohipse  has  been  reduced  ;  if  not,  extreme  caution  should 
be  exercised  on  approaching  this  point,  or  the  peritoneal  pouch  will  be  invaded. 
Portions  of  mucous  membrane  having  obvious  venous  dilatations  should  be 
carefully  avoided.  After  cauterization  dust  the  eschars  with  iodoform. 
During  recovery  and  some  time  thereafter  the  patient  should  be  confined  to 
bed  and  a  soft  stool  obtained,  while  in  the  recumbent  posture,  every  two  days 
witli  a  saline  laxative.  The  cautery  is  often  applied  before  the  reduction  of 
the  prolapse,  in  order  to  more  certainly  reach  the  upper  limit  of  the  afflic- 
tion. When  this  course  is  pursued,  the  reduction  of  the  prolapse  should 
follow  immediately,  to  avoid  strangulation  of  the  protrusion  by  the  sphincter. 

The  ])ossibility  of  reanimating  the  sphincter  after  restoration  is  some- 
what uncertain,  depending  of  course  on  the  degree  of  paralysis  and  the  length 
of  time  of  the  infliction.  Ofttimes  seemingly  hopeless  cases  are  markedly 
improved.  The  medical  expedients  directed  to  the  restoration  of  paralyzed 
muscles  may  be  employed  with  some  success. 


976  OPERATIVE   SURGEKY. 

The  removal  of  isolated  longitudinal  strips  of  mucous  membrane  at 
three  or  four  aspects  of  the  bowel  and  the  union  of  their  divided  borders 
is  sometimes  practiced  instead  in  cases  suitable  for  cauterization.  However, 
this  plan  has  nothing  to  commend  it  and  much  to  disapprove  of  as  a  substi- 
tute for  the  cautery. 

The  Treatment  of  Complete  Prolapse. — Complete  variety  of  prolapse  is 
met  in  three  forms :  1,  In  which  the  external  surface  of  the  prolapse  is 
devoid  of  a  sulcus ;  in  this  the  prolapse  follows  as  the  result  of  the  continu- 
ous traction  exerted  by  long-standing  prolapse  of  the  mucous  membrane. 
Peritoneum  is  present  in  the  tumor,  and  sometimes  also  a  loop  of  intestine 
(Fig.  1208,  e).  2,  In  which  a  sulcus  occurs  at  the  base  of  the  tumor,  at  the 
bottom  of  which  the  mucous  membrane  of  the  gut  can  be  felt  as  it  is 
reflected  from  the  invaginated  protrusion.  3,  In  which  the  finger,  when 
introduced  into  the  anus  beside  the  tumor,  fails  to  detect  any  evidence  of 
the  reflection  of  the  mucous  membrane  of  the  rectum  upon  the  tumor ;  in 
this  the  invagination  is  extensive,  involving  perhaps  the  colon,  caput  coli, 
and  sometimes  the  ileum  itself. 

Each  of  these  varieties  should  first  be  reduced ;  sometimes  reduction  is 
accomplished  with  great  difficulty  and  may  be  impossible,  especially  when 
an  acute  case  is  complicated  with  strangulation  of  the  protruding  portion, 
or  a  long-standing  prolapse,  attended  with  cohesions,  is  present. 

Tlie  Reduction  of  Prolapse. — Place  the  patient  in  the  knee-elbow  or 
knee-chest  (Fig.  1196)  position,  oil  the  protrusion,  and  carefully  endeavor 
to  return  the  part  first  that  escaped  last,  and,  if  necessary  for  the  purpose, 
the  external  sphincter  can  be  stretched  or  divided.  If  this  attempt  fail, 
renew  the  effort  by  trying  to  reduce  the  part  first  that  escaped  first.  If  the 
manipulation  be  very  painful,  the  mucous  membrane  of  the  protrusion  may 
be  painted  with  a  solution  of  cocain,  and  even  an  anaesthetic  may  be  given. 
To  the  reduction  of  the  third  variety  of  prolapse  must  be  added  the  copious 
injection  into  the  bowel  of  fluids  (page  G91)  or  gases,  tlie  introduction  of  the 
hand  (page  906),  by  c(pliotomy,  and  internal  restitution  and  fixation. 

Cripps  advises,  after  treatment  with  caustics  or  cautery,  that  a  thick 
rubber  tube  seven  inches  in  length,  with  a  third  of  an  inch  lumen,  be 
passed  up  the  rectum  for  about  five  inches.  Around  the  mucous  surface  of 
the  bowel  and  extending  upw^ard  as  "  high  as  possible  "  strips  of  oiled  lint 
are  arranged.  Finally,  between  the  oiled  lint  and  the  tube  is  carefully 
packed  cotton  wool  dusted  with  iodoform.  This  dressing  gives  a  fine  sup- 
port to  the  lower  part  of  the  bowel  and  permits  the  escape  of  flatus.  After 
forty-eight  hours  the  dressing  is  removed  and  the  parts  are  thoroughly 
cleansed.  In  a  few  days  the  tube  only  is  employed,  and  this  for  ten  days  or 
more.  He  advises  that  the  bowels  be  kept  quiet  for  ten  days  or  so  with 
small  doses  of  opium.  He  adds,  further  :  "  The  patient  must  on  no  account 
get  up  or  strain,  and  the  motion  is  to  be  passed  lying  on  the  side,  the 
anus  drawn  up  a  little  from  the  middle  line ;  and  this  should  be  enforced 
for  at  least  six  weeks,  while  consolidation  of  the  eschars  is  taking  place, 
otherwise  the  whole  advantages  of  the  operation  will  be  lost."  Should  the 
presence  of  the  dressing  cause  a  rectal  tenesmus  not  amenable  to  control  by 


OPP]RATIONS   ON   THE   ANUS   AM)    l{H(TrM. 


977 


modenitc  dosos  of  opium,  it  should  be  lessened  in  bulk  ;  I'liiling  then,  lu-nioved 
entirely. 

Lange's  Method  {I'mr/urr/Kiphy).  —  Place  the  patient  in  the  knee-chest 
j)(»sition;  expose  the  posterior  aspect  of  the  rectum  by  an  incision  made 
from  tlie  lower  part  of  the  sacrum  to  the  anus ;  remove  the  coccyx ;  intro- 
duce through  only  the  muscular  wall,  near  the  median  line,  longitudinally 
a  row  of  catgut  sutures  so  as  to  fold  inward  the  posterior  wall  of  the  bowel ; 
introduce  a  second  row  so  as  to  bring  the  lateral  walls  still  more  in  apposi- 
tion, thereby  burying  the  first  row  ;  unite  the  divided  borders  of  the  levator 
ani  and  external  sphincter  with  sutures;  till  the  cavity  with  gauze;  close 
the  integumentary  wound,  leaving  room  for  the  introduction  of  subsequent 
dressing  while  the  deep  parts  heal  by  granulation. 

The  RestfUs. — A  severe  prolapse  six  inches  in  length,  of  twenty  years' 
standing,  that  had  resisted  repeated  treatment  by  cautery  and  excision  of 
the  mucous  membrane,  was  cured  by  this  method. 

Roberts's  Method  {Elliptical  Excision)  (Fig.  1209). — Prepare  the  patient 
carefully  for  the  operation  ;  reduce  the  prolapse  while  in  the  lithotomy 
position ;  make  a  small  incision  in  front  of  the  coccyx  in  the  median 
line  of  the  perina?um  ;  intro- 
duce the  finger  through  the 
incision  behind  the  rectum 
and  break  up  for  three  inches 
its  posterior  cellular  connec- 
tions ;  introduce  a  scalpel 
through  the  dilated  anus  half 
an  inch  to  right  of  the  me- 
dian line,  and  make  a  deep 
incision  obliquely  backward 
and  inward  through  the 
sphincter  and  skin  to  the  Fm.  I209.-Operation  for  prolapse  of  the  rectum, 
^.  ...  Roberts  s  method,     o.  Anus  and  tnan^ejular  inci- 

primary  incision  at  the  end 

of  the  coccyx  ;  repeat  the  in- 
cision upon  the  left  side ;  re- 
move from  the  entire  thick- 
ness of  the  posterior  wall  of  the  rectum  a  triangular  piece  about  three  inches 
in  length  and  an  inch  at  the  base,  along  with  the  perineal  triangle,  with 
scissors;  ligature  the  bleeding  points  with  catgut;  unite  the  borders  of  the 
wound  from  above  downward  with  chromicized  catgut  or  sterilized  silk, 
placing  the  first  suture  at  the  apex  of  the  rectal  wound  ;  introduce  successive 
intrarectal  sutures  a  third  of  an  inch  apart,  the  last  one  being  located  just 
inside  the  margin  of  the  anus;  tie  the  sutures,  leaving  the  knots  within  the 
bowel ;  bring  together  and  unite  the  divided  ends  of  the  sphincter  with  a 
shotted  wire  and  two  catgut  sutures ;  introduce  a  drainage  tube  between  the 
rectum  and  sacrum  and  close  the  ano-coccygeal  wound  by  shotted  wire  sutures 
"  carried  deeply  through  the  structures  by  a  strong  curved  perineum  needle." 
Quietude  of  the  bowel  is  maintained  in  the  usual  manner  for  a  few  days,  and 
is  followed  by  an  oleaginous  or  saline  laxative. 


TUBEROSITY^ 


TUBEROSITY 


sion  of  the  perina-um,  with  sutures  placed.  Tri- 
angular section  of  posterior  wall  of  rectum,  with 
sutures  placed  for  tying,  seen  through  window 
in  anterior  wall. 


978 


OPERATIVE   SURGERY. 


Tlte  Eesults. — Inasmucli  as  the  healing  of  tlie  deep  parts  of  the  wound 
by  granulation  is  essential  to  a  cure,  the  recovery  is  somewhat  protracted  and 
the  formation  of  a  tistulous  canal  need  not  be  unexpected.  However,  the 
operation  is  a  good  one,  in  ordinary  cases  having  resulted  in  frequent  and 
final  relief. 

Mikulicz's  Method  {Amputation). — Place  the  patient  in  the  lithotomy 
position  and  thoroughly  cleanse  and  disinfect  the  prolapsed  i)ortion  ;  insert 
the  index  finger  of  the  left  hand  into  the  prolapse  and  divide  the  external 
tube  for  about  an  inch  parallel  to  and  an  inch  from  the  anal  margin  with 

a  knife  (Fig.  1210) ; 
pass  a  stitch  so  as 
to  unite  the  tubes 
together  (Figs.  003, 
905,  and  000),  if  the 
space  between  them  be 
unoccupied  by  small 
intestine;  tie  in  a  reef 
knot ;  leave  one  end 
short  and  free  and 
use  the  other  as  a  con- 
tinuous quilt  suture 
throughout  the  cir- 
cumference of  the 
bowel ;  sever  the  ex- 
ternal tube  as  the  sew- 
ing proceeds,  so  that 
cutting  and  sewing  will  cease  at  about  tlie  same  time;  cut  through  the 
internal  tube  and  unite  the  divided  edges  of  the  mucous  membrane  with 
a  continuous  suture  all  round ;  cleanse  the  stump  carefully  and  allow  it  to 
slip  within  the  anus. 

The  RemarTcs. — The  opening  into  the  peritoneal  cavity  that  attends  this 
procedure  bespeaks  the  employment  of  rigid  asepsis.  Unless  care  be  taken, 
the  stump  will  slip  away  as  soon  as  the  inner  tube  is  completely  divided. 
But  little  bleeding  attends  the  operation,  since  it  is  controlled  by  the  sewing. 
Treves's  Method  {Amputation). — Place  the  patient  in  the  lithotomy 
position  with  the  pelvis  well  raised  and  draw  down  the  prolajise  to  the  full 
extent ;  thoroughly  cleanse  the  field  of  operation  ;  divide  the  mucous  mem- 
brane of  the  outer  wall  of  the  prolapse  close  to  the  cutaneous  junction, 
entirely  round  the  base,  with  a  knife ;  separate  and  turn  down  toward  the 
apex  of  the  cone  the  mucous  cuff  of  the  prolapse,  by  means  of  scissors  and 
traction ;  cut  across  the  anterior  wall  of  the  prolapse  at  the  base  of  the  cone 
and  shut  off  the  peritoneal  cavity  with  a  sponge ;  rapidly  sever  the  remain- 
ing walls  of  the  prolapse  with  scissors,  seizing  each  inch  or  so  of  the  cut 
end  of  the  bowel  promptly  with  forceps,  to  arrest  ha?morrhage  and  prevent 
retraction  of  the  mucous  membrane ;  remove  the  sponge  from  the  peritoneal 
prolongation  and  close  the  opening  by  uniting  the  borders  of  the  divided 
membrane  by  several  fine  chromicized  catgut  sutures;  unite  the  divided  end 


Fig.  1210. — Operation  of  amputatinn  for  prolapse  of  the  rec- 
tum, Mikulicz's  method.     Primary  sutures  applied. 


()1M:KA'I'I(>XS   (».\    'I'lIK    AXIS    AND    I!  IIC'IT.M.  9^9 

of  the  bowel  to  the  luargiu  ol'  tlie  uiius  by  .silkuoi'iii-gut  sutures  going 
through  the  entire  thickness  of  the  wall  of  tlie  gut,  and  ligaturing  the  bleed- 
ing points  as  they  apjicur ;  cleanse  and  I'estore  the  })ai'ts  to  tiie  proper  site. 

Kleberg's  Method  {A)nput(ition). — Place  the  i)atient  in  the  lateral  posi- 
tion, with  the  })elvis  raised  and  the  shoulders  turned  downward,  on  the 
operating  table  as  far  as  possible  ;  administer  the  ana'sthetic  ;  cause  an 
assistant  to  grasp  the  prolapsus  with  both  hands  with  the  lingers  extended 
downward,  and  press  as  hard  as  possible  against  the  protrusion  at  a  point  just 
below  the  sphincter;  pass  upward,  beneath  the  hands  of  the  assistant, around 
the  tumor  to  its  base  a  strong  rubber  tube,  and  draw  it  only  tight  enough  to 
arrest  the  circulation ;  fasten  the  tubing  securely,  and  direct  the  assistant 
to  relax  his  grasp ;  make  a  longitudinal  incision  anteriorly  two  inches  long 
through  the  prolapsed  rectum  ;  cut  the  peritoneal  sac  at  that  situation ; 
seize  the  elastic  ligature  with  forceps,  and  prevent  its  displacement  down- 
ward into  the  incision  ;  push  back  into  the  peritoneal  cavity  any  prolapsed 
small  intestine  ;  thrust  a  large-sized  Leuer's  pocket  trocar  from  before  back- 
ward immediately  below  the  ligature  through  the  prolapse;  remove  the  tro- 
car, leaving  the  canula  behind;  pass  tw'o  elastic  drainage  tubes  each  a  line 
and  a  half  in  diameter  through  the  canula,  and  remove  it ;  tie  the  ligatures 
tightly  at  the  respective  sides  of  the  prolapse ;  remove  the  primary  elastic 
constriction,  and  cut  off  the  prolapsus  an  inch  below  tlie  secondary  ligatures 
with  scissors ;  knead  the  parts  above  the  ligatures  with  the  fingers  for  a  few 
moments  to  displace  upward  the  fluids;  protect  the  parts  around  the  stump 
with  cotton,  and  soak  the  stump  below  the  ligature  with  a  mild  solution  of 
chloride  of  zinc ;  dry  the  stump,  knead  the  soft  parts  as  before,  and  apply 
again  the  chloride  of  zinc  ;  cover  the  whole  with  dry  cotton  batting,  and 
cause  it  to  be  removed  as  soon  as  moist ;  reapply  dry  cotton  batting,  and 
allow  the  free  access  of  air  to  the  parts. 

The  Precautions. — The  pressure  of  the  rubber  tube  prevents  the  entrance 
through  the  incision  of  air  or  blood  during  the  return  of  the  intestine.  Be- 
fore transfixion  with  the  trocar,  be  sure  that  the  peritoneal  prolongation  is 
empty.  If  silk  ligatures  be  tied  around  the  knots  of  the  elastic  ones,  these 
knots  will  be  much  more  secure. 

The  Results. — In  a  patient  to  whom  this  treatment  w^as  applied  by  Kle- 
berg a  prolapsus  a  foot  in  length  and  six  inches  in  diameter  was  removed. 
At  the  end  of  two  months  the  patient  had  recovered  completely.  In  another 
case  a  fatal  result  followed,  due  perhaps  to  the  bad  state  of  the  patient's 
health. 

Verneuil's  Method  {Proctopexy). — Put  the  patient  in  the  lithotomy  posi- 
tion and  restore  in  place  the  prolapse ;  make  outward  at  right  angles  with 
the  antero-posterior  diameter  of  the  anus  from  either  side  of  the  opening  an 
incision  through  the  integument  and  external  sphincter,  about  an  inch  in 
length ;  make  an  incision  from  the  tip  of  the  coccyx  at  each  side  so  as  to 
meet  the  terminal  points  of  the  preceding  ones;  dissect  and  raise  from 
behind  forward  the  triangular  flap,  including  the  subcutaneous  cellular  tis- 
sue and  the  fibers  of  the  external  sphincter,  leaving  them  attached  at  the 
base  to  the  tissues  surrounding  the  anus;  draw  the  flap  strongly  upward, 
68 


980 


OPERATIVE  SURGERY. 


Fig.  1211. — Operation  for  prolapse  of  the  rectum, 
Tattle's  metliod.  a.  Line  of  incision  midway 
between  apex  of  coccyx  and  base  of  prolapse. 
b.  Prolapsed  rectum. 


and  loosen  the  posterior  wall  of  the  rectum  for  a  distance  of  two  to  two  and 
a  half  inches  in  width,  and  to  a  height  equal  to  tlie  distance  from  the  anus 
to  the  point  of  the  coccyx.  Pass  four  threads  parallel  with  each  other  trans- 
versely through  the  posterior  wall  of  the  rectum,  not  including  the  mucous 
membrane,  placing  the  upper 
at  a  point  corresponding  with 
the  tip  of  the  coccyx,  and  the 
lower  three  fifths  of  an  inch 
from  the  anus;  pass  a  needle 
with  the  eye  at  the  point,  from 
without  inward  through  the 
skin  at  places  situated  an  inch 
and  a  half  from  the  median 
line  at  either  side,  and  with- 
draw the  needle  in  turn  with 
the  corresponding  end  of  each 
suture.  The  extremities  of  the 
upper  suture  should  escape  on 
a  level  with  the  sacro-coccygeal 
junction,  and  those  of  the  lower  at  the  tip  of  the  coccyx.  Place  the  remain- 
ing sutures  equidistant  between  them ;  tie  together  at  the  respective  sides 
the  extremities  of  the  first  and  second  and  third  and  fourth  sutures  over  rolls 
of  gauze  placed  beneath  the  loops  to  prevent  their  burial  in  the  tissues 
from  the  strong  traction  made  to  secure  the  rectum  in  the  new  position ; 
insert  a  drainage  tube;  replace  and  unite  the  triangular  flap  in  its  former 

position.  The  anus  is  narrowed 
by  suturing  the  margins  caused 
by  the  outward  lateral  incisions. 
The  Remarks. — It  is  sug- 
gested that  the  beginning  of  the 
primary  incisions  should  corre- 
spond to  the  limit  in  front  of 
the  amount  of  dilated  anal  tis- 
sue needed  to  form  a  new  anus 
of  suitable  size. 

Tuttle's  Method  {Procto- 
pexy).— This  heretofore  unpub- 
lished method  is  thus  described 
by  Dr.  Tuttle  himself:  "The 
operation  is  applicable  to  all 
prolapses  of  the  rectum,  begin- 
ning below  the  recto-sigmoidal  juncture — i.  e.,  the  first  and  second  degrees 
of  complete  prolapse  (Fig.  1211).  It  is  based  upon  the  fact  that  such  pro- 
lapses are  due  to  the  relaxation  or  giving  way  of  the  attachments  of  the 
rectum  to  the  sacrum  and  perirectal  tissues,  and  that  the  rational  method 
of  cure  would  be  to  restore  these  attachments  and  hold  the  rectum  in  its 
normal  position  until  they  become  strong  enough  to  retain  it  there.     Place 


Fig.  1313. — Operation  for  prolapse  of  the  rectum, 
Tuttle's  method.  Gut,  d,  invaginated  through 
incision.  «,  h,  c.  Sutures  passed  through  mus- 
cular wall  of  gut. 


OPERATIONS  OX   TIIK    ANl'S    AND    RKCTl'M. 


981 


Fig.  1313.— Operation 
Tuttle's  method, 
out  at  sides  of  sacriiin. 


'or  pnjiapse  of  the  rectum, 
Sutures  passed  upward  and 


the  jiiitiont  on  the  side,  with  the  liips  raised.  Thoroughly  disinfect  the 
rectum  and  external  parts.  A  scMiiiciiciilar  incision,  about  one  to  two  inches 
long,  is  then  made  midway  between  the  anus  and  coccyx,  and  extended  into 
the  cellular  tissiu>  between  tlie  rectum  and  sacrum.  With  the  finger  or  a 
long,  blunt-i)()iiited,  curved  scissors  the  rectum  is  then  separated  from  the 
sacrum,  as  high  u])  as  the  length  of  the  j)rotruding  gut.  The  sacral  surface 
of  the  cavity  thus  made  is  gently  curetted,  to  remove  all  fat  and  freshen 
the  surfaces  for  future  union 
with  the  gut.  With  the  aid  of 
an  assistant's  finger  in  the  rec- 
tum, the  gut  is  invaginated 
(Fig.  1212)  through  the  semi- 
circular incision  and  drawn 
down  as  far  as  it  will  come. 
The  external  surface  of  the 
posterior  wall  of  the  gut  being 
thus  exposed,  is  curetted  and 
freshened  down  to  the  muscu- 
lar layer.  Long  silkworm-gut 
sutures  are  now  passed  trans- 
versely throttgh  the  muscular 
wall  of  the  gut,  taking  a  bight 
of  a])out  one  inch  or  more  each, 
their  ends  being  left  free.  From 
three  to  five  of  these  sutures 
are  put  in,  about  one-half  inch 
apart.  Then,  with  a  long  Peas- 
lee  needle,  the  ends  of  the  su- 
tures are  carried  up  through 
the  wound  (Fig.  1213)  and  be- 
tween the  rectum  and  sacrum, 
and  brought  out  through  the 
ligaments,  fascia?,  and  skin,  one 
end  on  one  side  of  the  bone  and 
one  upon  the  opposite  side.  The 
upper  sutures  in  the  gut  are 
brought  out,  if  possible,  a  little 
higher  than  the  normal  position 
of  this  portion  of  the  rectum. 
When  the  sutures  have  been  thus 
passed,  they  are  drawn  taut  suc- 
cessively from  above  downwards,  and  tied  over  a  fold  of  iodoform  gauze  to 
prevent  their  cutting  into  the  skin  (Fig.  121-4).  The  rectum  is  thus  held  in 
its  normal  position  by  the  sutures,  which  are  left  in  for  ten  days  to  two  weeks. 
A  buried,  circular,  kangaroo-tendon  ligature  is  passed  around  the  rectum,  on 
a  level  wdth  the  upper  margin  of  the  external  sphincter,  and  tied  tight  enough 
to  constrict  the  iiwiex  finger  passed  into  the  anus.    The  operation  is  completed 


Fig.  1214. — Operation  for  jirolapse  of  the  rectum, 
Tuttle's  method.  a,  b,  c.  Sutures  tied  over 
sacrum,  gauze  intervening,  cl.  Original  wound 
closed,  e.  Buried  circular  ligature  for  narrow- 
ing anus  and  supporting  sphincter.  /.  Outline 
of  reduced  rectum. 


982 


OPERATIVE  SURGERY. 


by  closing  the  semicircuhir  iiici.sion  posterior  to  the  anus  with  chrornicized  gut 
sutures  passed  deep  enough  to  bring  together  the  ends  of  the  recto-coccygeus 
and  external  sphincter  muscles,  which  will  have  been  cut.  The  patient  is  kept 
in  bed  for  three  weeks,  and  his  bowels  are  moved  by  enema  on  the  eighth  day." 
llie  Results. — Five  cases  have  been  operated  on  by  Dr.  Tuttle,  41,  31, 
30,  and  21  months  ago  respectively.     The  fifth  case  is  of  too  recent  date  to 

merit  attention  in  this  connection.  In 
four  cases  the  average  length  of  the 
prolapse  and  of  the  time  of  infliction 
was  3.75  inches  and  7  years  respectively. 
Prompt  recovery  and  no  return  charac- 
terize each  case. 

Peters' S  Method  {Proctopexy). — Pe- 
ters carried  into  effect  an  operation  as 
follows  (Fig.  1215)  :  Open  the  abdomen 
in  the  median  line ;  seize  and  draw  up- 
ward the  rectum,  restoring  the  prolapse; 
narrow  the  lumen  of  the  lower  portion 
of  the  bowel  by  infolding  its  anterior 
wall  and  confining  the  infold  in  place 
by  six  silk  sutures  so  passed  as  to  em- 
brace only  the  serous  and  muscular  coats 
[a  and  c).  The  lowest  stitch  should  be 
placed  as  near  to  the  anus  as  is  possible. 
If  now  the  rectum  be  stitched  to  the 
abdominal  wall  {!))  as  high  up  as  possible 
by  means  of  the  long  ends  of  the  su- 
tures, permanent  restoration  may  be  ex- 
pected. A  case  of  two  years'  standing 
without  return  is  reported. 
Colopexy. — Colopexy  consists  in  the  elevation  and  fixation  of  the  bowel  to 
some  jmrt  of  the  abdominal  wall  for  the  cure  of  severe  cases  of  rectal  prolapse. 

The  operation  was  devised  and  performed  first  by  Jaennel  on  February  5,  1889. 
He  opened  the  abdomen  in  the  iliac  region  as  for  the  formation  of  artificial  anus, 
raised  the  intestine  out  of  the  wound,  and  drew  it  upward  so  as  to  reduce  the  pro- 
lapse of  the  rectum.  He  confined  the  bowel  in  place  by  stitching  it  to  the  borders 
of  the  wound,  and  by  the  support  of  a  steel  sound,  surrounded  by  gauze,  carried 
tiirough  the  mesentery,  permitted  it  to  lie  on  the  abdomen.  An  artificial  anus  was 
made  on  the  sixth  day  following  the  operation  ;  a  movement  occurred  on  the  eighth, 
and  the  sound  was  removed  on  the  ninth  day.* 

The  writer  operated  on  a  long-standing  case  of  prolapse  of  the  rectum  that  had 
resisted  other  curative  measures,  on  October  31,  1896.  At  the  time  of  the  operation 
the  prolapse  was  two  and  a  half  inches  in  length  and  five  inches  in  circumference.  It 
could  be  readily  reduced  by  the  patient,  and  remained  up  e.xcept  with  the  act  of  defe- 
cation.    The  sphincter  was  feeble,  the  voluntary  action  being  scarcely  aj)j)arent. 


Fig.   1215.— Operati< 
the  rectum,  Peter 
c.  Infolding  the  rectum 
inal  wall. 


fur    pro 

method 

b. 


iujise    f)f 

a  and 

Abdoin- 


*  Extract  from  a  paper  by  the  author,  published  in  the  Annals  of  Surgery,  August, 

1897. 


Ol'KKA'rioNS   ON    TIIK    ANTS    AND    I{K(Tl'>[. 


1»83 


The  Operdtimi. — An  incision  tliri-e  inclu-s  in  length,  about  an  inch  above 
anil  parallel  with  Poupart's  ligament,  which  was  made  down  to  and  through 
the  peritonaeum.  The  peritonaeum  was  separated  from  the  superimposed 
tissues  at  either  side  for  an  inch  at  least,  but  farther  above  than  below. 
The  gut  was  pulled  upward  firmly,  causing  the  prolapse  to  disappear  en- 
tirely; and,  while  the  gut  was  being  thus  held,  any  relaxed  tissue  of  the 
rectum  within  reach  was  drawn  down.  During  firm  traction  upward  on  the 
gut  the  peritoneal  flaps  of  the  wound  were  joined  to  it  by  quilting  and  con- 
tinuous sewing  with  silk,  the  stitches  including  the  muscular  coat  of  the 
intestine  (Fig.  1210).  Six  silk  sutures  were  carried  through  the  borders  of 
the  abdominal  wound 
so  as  to  include  the 
muscular  coat  of  the 
gut,  behind  the  longi- 
tudinal band.  The 
longitudinal  baud  was  drawn 
forward  into  the  wound  al- 
most to  the  external  limit, 
the  sutures  were  tied  firmly, 
thus  causing  the  border  of 
the  wound  to  grasp  the  en- 
tire band  and  a  small  portion 
of  the  intestinal  wall.  The 
wound  healed  promptly  with- 
out an  untoward  manifesta- 
tion. The  patient  was  kept 
in  bed  for  three  weeks,  after 
which  he  was  allowed  entire 
freedom  of  action  in  all  re- 
spects. Xo  distinct  rectal 
protrusion  appeared  after  def- 
ecation, or  with  the  effort, 
during  the  two  and  a  half 
years  that  the  patient  re- 
mained under  observation. 

The  Results. — In  30  cases 
of  colopexy  non-recurrence 
is  stated  in  22,  partial  recur- 
rence in  3,  and  recurrence  in  4.  Not  a  single  death,  and  no  other  sequels 
except  a  hernial  protrusion  in  one  case,  is  reported.  No  comments  bearing 
on  the  facts  of  annoyance  or  suffering  of  any  kind  during  convalescence  are 
expressed. 

Introduction  of  Bougies,  etc.,  to  the  Rectum. — Empty  and  cleanse  the 
rectum  and  place  the  patient  in  either  one  of  the  three  positions  for  rectal 
examination  (page  00.5) ;  inject  into  the  rectum  an  ounce  or  so  of  sterilized 
oil ;  grasp  and  carry  the  bougie  (Fig.  121T)  from  behind  forward  toward  the 
navel  along  the  anal  axis,  then  change  the  direction  to  backward,  upward, 


Fig 


.  1216. — Operation  of  colopexy  for  prolapsed  rec- 
tum, author's  method,  a.  a.  Fibrous  band  of 
intestine,  b.  h.  Parietal  peritonaeum  quilted  and 
sewed  to  intestine  at  either  side.  c.  Old  fistulous 
opening. 


984 


OPERATIVE   SURGERY. 


Fig.  1217.— The 


introduction  of 
the  rectum. 


bulbous   bougie  into 


The  employmeut 


and  to  the  left  in  accordance  with  the  directions  of  the  respective  curves 
(page  !)(i;3),  without  the  use  of  force. 

The  Reniarks. — 'IMie  introduction  directly  upward  into  the  anus  of  the 
tube  of  a  syringe  encroaches  painfully  on  the  superior  wall  of  the  anal  curve, 
and  the  tube  is  often  arrested  by  it.  The  intra- 
rectal folds  not  infrequently  arrest  the  upward 
course  of  the  bougie,  requiring  a  change  of  direc- 
tion to  effect  further  admission.  In  normal  con- 
ditions the  bougie  will  pass  up  to  near  the  middle 
of  the  sigmoid  flexure.  If  this  portion  of  the  intes- 
tine or  its  mesentery  be  unusually  long  the  end  of 
the  instrument  may  be  felt  beneath  the  skin  in 
the   hypochondriac  region. 


High  injections  are  intro- 
duced with  the  patient  in 
the  knee-elbow  position  or 
while  lying  on  the  side  with 
the  pelvis  elevated.  Rubber 
instruments,  or  those  hav- 
ing a  rubber  tip,  are  pref- 
erable, since  there  is  less  danger  of  injury  from  their  use 
of  care  without  vigor  in  the  introduction  is  the  only  assurance  of  safety. 

Proctotomy. — Proctotomy  is  an  operation  done  for  the  relief  of  obstruc- 
tion and  constriction  of  the  lumen  of  the  rectum  dependent  on  stricture 
from  whatever  cause,  atresia,  and  for  the  removal  of  foreign  bodies.  Inter- 
nal and  external  proctotomy  are  practiced. 

Internal  Proctotomy. — Internal  j^roctotomy  is  directed  to  division  of 
stricture  or  atresia  of  the  rectum,  and  the  nearer  the  obstruction  is  to  the 
anal  end  of  the  gut  the  easier  the  division. 

The  Operatiott. — Cleanse  the  bowel,  administer  an  anajsthetic,  and  place 
the  patient  in  the  litliotomy  position ;  dilate  the  anus  and  expose  the  stric- 
ture with  the  aid  of  a  speculum  and  light ;  introduce  a  straight  probe-pointed 
bistoury  through  the  stricture  at  the  seat  of  most  decided  development,  and 
cut  carefully  outward  through  the  stricture  sufficiently  to  reach  the  healthy 
tissues.  One  or  more  incisions  are  made  as  need  be.  Immediately  after  the 
cutting,  fill  the  bowel  with  oiled  wool  or  lint  for  twenty-four  hours,  then 
remove  and  introduce  a  vulcanite  tube  with  a  slotted  collar  for  top  attach- 
ment to  hold  it  in  position  (Allingham).  CrecWs  rectal  bougie  is  useful  in 
such  cases. 

The  Remarks. — The  vulcanite  tube  is  worn  more  or  less  continuously, 
except  at  defecation,  so  long  as  there  is  a  tendency  to  contraction.  Complete 
division  of  the  stricture  at  three  or  four  points,  without  too  great  involvement 
of  the  healthy  tissue,  requires  exceeding  caution  in  order  not  to  penetrate 
the  bowel  or  expose  too  extensively  the  divided  healthy  tissues  to  the  danger 
of  infectiou. 

Bacon's  Method. — Bacon  came  to  the  conclusion  that  the  only  rational 
method  of  curing  troublesome  strictures  located  above  the  levator  ani  was 


orKUATIUN'S   ON    TllH    A.N  US    AND    RECTUM. 


085 


"by  foriDing  ii  new  chtinnel  around  the  stricture  by  folding  the  gut  imme- 
diiitely  above  tlie  constricted  portion  down  over  the  stricture  an(i  anastomos- 
ing it  witli  the  rectum  below  the  narrowed  part."  Following  this  the  septum 
was  clamped  away  leaving  a  capacious  channel. 

The  Operation. — Place  the  patient  in  Trendelenburg's  position  and 
make  an  incision  in  the  median  line  from  the  pubes  to  the  umbilicus;  pull 
apart  tiie  borders  of  the  wound,  freely  exposing  the  rectum  and  sigmoid 
flexure  (Fig.  r^l8) ;  locate  the  seat  and  extent  of  the  strictured  part  (*)  ; 
estimate  the  proper  site  of  anastomosis  by  aj)plyiug  the  sigmoid  flexure  {e) 
to  the  rectum  {d)  below  the  seat  of  stricture;  draw  the  sigmoid  flexure  up 
into  the  wound  and  introduce  into  it  in  the  usual  manner  the  male  segment 
of  the  Murphy  button  ;  return  it  to  the  selected  site  for  anastomosis  and 


Fk;.  1218.  Fio.  1219. 

Fu;.  1218. — Operation  for  stricture  of  tlie  rectum.  Bacon's  inetliod.  a.  b.  Upper  limit  of 
levator  aiii  muscle,  r.  Anastomotic  opening  between  rectum  and  sigmoid  flexure. 
e.  Sigmoid  flexure,     d.  Rectum.    /.  Anus.     *  Seat  of  stricture. 

Fig.  1219. — Operation  for  stricture  of  the  rectum.  Bacon's  method.     Spiral  instrument 
for  insertiim  of  female  segment  of  button. 


introduce  the  female  segment  of  the  button  through  the  anus  (/)  up  to  the 
lower  limits  of  the  stricture  by  means  of  a  special  trocar-pointed  instrument 
(Fig.  I'^IO)  so  constructed  as  to  deposit  the  shank  of  the  segment  in  the 
channel  caused  by  the  perforation  of  the  trocar ;  lock  together  the  respective 
portions  of  the  button  in  the  usual  manner ;  stitch  the  previously  scarified 


986 


OPERATIVE  SURGERY. 


^^5. 


contiguous  serous  surfaces  of  the  intestine  closely  together  (c,  c,  Fig.  1220) 
to  prevent  the  small  intestine  from  slipping  between  them.  After  escape  of 
the  button  wash  out  thoroughly  the  rectum  and  colon,  and  introduce,  as 
indicated  m  the  illustration  (Fig.  1220),  a  suitable  clamp,  which  is  caused 
to  grasp  the  contiguous  surfaces  and  is  tightened  from  day  to  day  until  the 
septum  is  destroyed  and  the  spur  removed. 

The  Remarks. — The  button  is  usually  expelled  during  the   first  week. 

The  largest  sized  button  is  the  best  for  the 
purpose.  The  septum  is  severed  by  the  clamp 
at  the  end  of  the  third  or  fourth  day.  Strict 
asepsis  is  demanded  throughout.  The  special 
instrument  for  depositing  the  female  half  may 
be  extemporized. 

The  Precautions. — If  the  small  intestine 
should  slip  between  the  folds  the  application 
of  the  clamp  will  cause  prompt  and  complete 
intestinal  obstruction.  Therefore,  early  and 
perfect  apposition  is  sought  for  by  means  of 
scarification  and  suturing. 

Tlie  Results. — A  sufficient  number  of  suc- 
cessful cures  are  noted  to  commend  the 
method  in  suitable  cases. 

Bacon  proposed  somewhat  later  the  follow- 
ing plan  for  the  treatment  of  stricture  located 
just  above  the  internal  sphincter :  With  the 
patient  under  anesthesia,  and  tlie  rectum 
thoroughly  cleansed,  puncture  the  posterior 
wall  just  above  the  internal  sphincter  with  an 
aneurism  needle  armed  with  a  heavy  silk  liga- 
ture (Fig.  1221) ;  carry  the  point  of  the  instru- 
ment back  into  the  perirectal  tissue  behind 
the  stricture,  thence  upward  and  through  into 
the  bowel  above  the  upper  limit  of  the  stric- 
PiG.  1220.— Operation  for  stricture    ture.      The  needle  is  withdrawn,  leaving  the 

of  the  rectum  Baeon-s  method,    ligature  surrounding  the   stricture  and'^with 

a.  Blade  or  clamp  passing  into    ,      ,  ,     ,  ° 

sigmoid  flexure  througli  anas-    both  ends  hanging  from  the  anus.     The  ends 

tomotic  opening,    h.  Stricture,    are  tied  together  and  the  loop  kept  in  place  for 

c,  c.    Supplementary    sutures.    ,^    .  °  ,     ,,  ^        ^  ^        . 

d.  Rectum,   e.  Sigmoid  flexure.       about  three  months     to  secure  a  "  continu- 

ous tract "  (  /"),  after  which  the  suture  is  with- 
drawn, a  grooved  director  inserted  along  its  course,  and  the  intervening  tissue 
divided  freely  with  the  cautery  into  the  rectum,  thus  severing  the  stricture. 

The  Remarks. — The  idea  is  to  establish,  by  means  of  the  fistula,  a  tract 
which  will  remain  unhealed  after  division  of  the  intervening  tissues,  thus 
preventing  their  union  and  the  subsequent  return  of  the  constriction. 

The  free  drainage  prevents  infection  and  little  or  no  annoyance  attends 
the  treatment.  The  jjatient  is  usually  kept  in  bed  a  week  after  the  insertion 
of  the  seton  and  another  week  after  division  of  the  stricture. 


(>im:ua  rioNs  on  Tiih:  ants  and  i{K("ir:\i. 


087 


^^mmm/ff^.^ 


% 


# 


.-.^^ 


^^. 


% 


% 


Fig.  1221. — Opei'atioii  for  low  stricture  of 
the  rectuiii,  Bacoirs  iiietliod.  a,b.  Sep- 
iinilioii  of  Willi  of  gut  (e,  d)  after  inci- 
sion through  "continuous  tract  "  (/). 


T/ie  JkesiiUs. —  />(iro)i  reports  several  cases  as  "apparently  cured  "  and 
three  as  "  j)artial  failures."  He  accounts  for  the  latter  because  of  failure  to 
include  with  the  ligature  all  of  the  scar 
tissue  above  and  below  the  constric- 
tion. Tlu'  real  merits  of  this  plan  con- 
sist in  the  simplicity  and  the  avoidance 
of  division  of  the  sphincter  and  its 
consequent  annoyances. 

IlartituDui  advocated  for  treatmeiii 
of  difficult  stricture  dilatjition  of  tlic 
anus,  the  seizing,  pulling  down,  and 
isolation  of  the  stricture,  followed  by 
section  of  the  rectum  and  union  of  the 
superior  extremity  to  the  integumen- 
tary border. 

However,  it  appears  that  at  the  end 
of  a  few  days  the  stitches  cut  out  and 
the  upper  end  ascends  somewhat,  but 
not  sufficiently  to  materially  affect  the  results.  A  tube  surrounded  with 
iodoform  gauze  should  be  introduced  and  kept  in  place  by  gauze  and  a 
perineal  bandage. 

The  Remarhs. — Hartmann  highly  commended  this  plan  because  of  its 
rapidity,  simplicity,  and  the  slight  injury  it  causes.  We  are  not  disposed  to 
regard  it  in  the  same  light,  except,  perhaps,  when  the  stricture  is  so  close  to  the 
anus  as  to  render  the  division  of  serous  membrane  impossible,  and,  too,  when 
the  accepted  retraction  is  not  followed  by  subsequent  stricture  formation. 

External  Proctotomy  {Linear  or  Posterior  Proctotomy). — In  external 
proctotomy  the  rectum  is  opened  from  behind  for  the  removal  of  foreign 
bodies  and  tumors,  and  for  the  division  of  malignant  stricture. 

llie  Ojjeration. — Prepare  and  place  the  patient  as  before  ;  open  the  bowel 
completely,  from  and  including  the  anus  upward  and  backward  even  to  the 
coccyx,  with  the  ecraseur,  galvano-cautery,  or  the  knife.  The  knife  is  em- 
ployed most  frequently,  and  in  either  of  the  following  manners : 

a.  Expose  the  lower  part  of  the  stricture  by  cutting  through  the  tissues 
behind  and  below  the  stricture  with  an  ordinary  scalpel,  and  then  divide  the 
stricture  completely. 

h.  Pass  through  the  stricture  a  sharp-pointed  curved  bistoury  or  ordinary 
scalpel;  turn  the  edge  backward  at  the  median  line  posteriorly  and  cut 
directly  through  to  the  external  wound.  Ligature  the  bleeding  points; 
pack  the  wound  firmly  with  iodoform  gauze  to  check  oozing  and  prevent 
infection.     The  wound  is  dressed  as  often  as  cleanliness  requires. 

The  Remarks. — The  division  can  be  made  from  without  inward  with 
almost  equal  facility.  Posterior  proctotomy  provides  ample  drainage  and  a 
full  opportunity  to  secure  cleanliness,  both  of  which  are  denied  by  incom- 
plete internal  incision. 

The  Re.sidfs. — The  death  rate  from  this  practice  is  not  insignificant,  and 
thereafter  the  duration  of  life  is  about  100  days.     Whenever  the  disease  can 


988  OPERATIVE   SURGERY. 

be  removed  and  equal  comfort  assured  by  other  means  proctotomy  should 
not  be  practiced. 

Proctectomy. — Proctectomy  signifies  partial  or  complete  removal  of  the 
rectum,  and  as  a  curative  or  palliative  measure  is,  at  the  present  time,  a 
generally  accepted  surgical  procedure.  It  can  be  stated  as  a  conservative 
precept,  however,  that  if  the  upper  limit  of  the  growth  can  not  be  easily 
reached  with  the  index  finger,  its  removal  should  be  contemplated  more 
seriousl}',  owing  to  the  contiguity  of  the  peritonaeum.  Still,  even  under 
these  circumstances,  if  the  mucous  membrane  only  be  involved,  the  diseased 
structure  can  sometimes  be  stripped  off  without  entering  the  peritoneal 
cavity.  If  contiguous  viscera  be  involved,  or  the  pelvic  lymphatic  glands  be 
enlarged,  the  expediency  of  the  operation  is  decidedly  questionable.  The 
presence  of  ulceration,  stricture,  or  cancer  may  call  for  the  operation.  When 
done  through  the  j9er«;iC5z<wi,  through  the  sao-um,  or  through  the  vagina, 
it  is  called  2)erineal,  sacral,  or  vaginal  proctectomy,  respectively. 

The  Preparation  of  the  Patient. — Inasmuch  as  the  preparation  of  the 
patient  is  substantially  alike  in  each  method  of  operation,  a  single  statement 
will  suffice.  The  bowels  should  be  cleared  out  two  or  three  days,  and  again 
the  night,  before  the  operation.  The  external  parts  should  be  thoroughly 
shaved,  scrubbed,  and  purified,  tlie  bladder  emptied,  and  the  rectum 
cleansed.  Tlie  diet  should  be  light  and  absorbable  for  some  days  before. 
A  rigid  course  of  ^preparation  can  be  practiced,  as  the  giving  of  a  dose  of 
castor  oil  daily  for  four  or  five  days  before  the  operation ;  a  diet  limited  to 
sterilized  milk,  and  the  administration  of  a  half  drachm  each  of  na2)ht]iol 
and  salicylate  of  magnesia,  thereby  rendering  the  stools  odorless  and  innocu- 
ous (Boutier).  The  mucous  membrane  of  the  bowel  should  be  made  aseptic, 
and  the  lumen  above  closed  with  a  sponge  with  a  string  attachment.  The 
rate  of  recovery  from  the  operation  is  regarded  by  some  to  be  in  direct  pro- 
portion to  the  degree  of  cleanliness  exercised  in  the  preparation  and  during 
the  operation.  Preliminary  colostomy  in  large  and  extensive  growths  and 
otherwise  severe  cases  is  advisable.     Better  asepsis  is  thus  secured. 

Perineal  Proctectomy  {AJUngham). — Although  somewhat  of  a  misnomer, 
the  expression  perineal  proctectomy  serves  well  to  distinguish  this  line  of 
approach  from  that  of  either  of  those  more  definitely  indicated. 

The  Operation. — Place  the  patient  in  the  litliotomy  position ;  make  an 
oval  incision  between  the  external  and  internal  sphincters,  if  practicable 
around  the  bowel,  passing  into  both  ischio-rectal  fosste ;  prolong  the  incision 
backward  to  the  coccyx  (Fig.  l--i22),  and  separate  the  bowel  at  the  sides  and 
posteriorly  as  high  as  the  levator  ani  by  blunt  dissection  ;  support  the  bowel 
during  dissection  by  means  of  the  finger  within  the  rectum  and  the  thumb 
without,  carefully  observing  that  no  encroachment  be  made  on  contiguous 
passages  (Fig.  1223) ;  introduce  through  the  anus,  guided  by  the  finger,  a 
sharp-pointed  bistoury,  and  transfix  tlie  bowel  posteriorly  opposite  the  tip 
of  the  coccyx;  lay  open  in  the  median  line  the  posterior  part  of  the  bowel ; 
arrest  haemorrhage,  and  introduce  long  traction  sutures  at  either  side  of  the 
w^ound,  and  draw  the  borders  widely  apart ;  carry  an  incision  round  the 
amis  at  the  muco-cutaueous  junction  if  the  anus  is  to  be  preserved  ;  if 


OPKKA'IMOXS   UN    Till-:   ANUS   AM)    KKCTIM. 


989 


Fi(i.   1222. — The  operation   of   iHiim  il    piiiiiiciuiiiy,  Alling- 
hanrs  iiictliod.     Line  ol  iiiei>iuii. 


not,  begin  beliiiul  iit  tlie  vorticiil  wound  in  etich  instance,  and  carry  the 
incision  through  the  skin  external  to  the  anus  sulliciently  far  to  permit  a 
coin})k'te  removal  of  the  disease,  cutting  freely  into  tiie  ischio-rectal  fossai  at 
either  side ;  free  the  lateral  and  posterior  parts  of  the  rectum  by  blunt  dis- 
section with  the  lin- 
gers and  blunt  scis- 
sors, snipping  the 
fibers  of  the  levator 
ani;  introduce  a  sound 
into  the  urethra  of  the 
male,  the  finger  into 
the  vagiiui  of  the  fe- 
male, to  guide  the  sep- 
aration of  the  anus 
and  tissues  in  front 
and  preserve  the  in- 
tegrity of  important 
structures ;  seize  the 
lower  end  of  the  rec- 
tum with  forceps,  and  draw  downward  and  from  side  to  side  as  required  to 
facilitate  the  continued  separation  of  the  bowel ;  free  the  rectum  all  round 
to  well  above  the  limits  of  the  disease ;  sever  the  rectum  transversely  in 
sections  with  scissors,  closing  the  bleeding  points  as  they  arise  with  pressure 
forceps,  through  which  means  control  of  the  proximal  end  of  the  gut  is  also 
maintained;  syringe  and  dry  out  the  wound  cavity;  ligature  vessels  and 
check  oozing ;  draw  the  mucous  membrane  down  and  stitch  it  to  the  border 
of  the  integument  if  practicable ;  if  not,  stitch  it  to  other  tissues,  all  low 
down  as  feasible,  and  irrigate,  dry  and  dust  the  raw  surface  with  iodoform  ; 

introduce  a  large- 
sized  Rubber  tube  into 
the  bowel,  and  pack 
around  it  iodoform 
gauze ;  allay  pain  and 
irritation  with  opium 
for  a  few  days,  main- 
taining cleanliness ; 
after  two  weeks  in- 
troduce daily,  for  a 
month,  a  full-sized 
rectal  bougie  ;  allow 
it  to  remain  for  some 
hours;  at  each  intro- 
duction pass  thereaf- 
ter daily  for  a  year  or  more,  or  so  long  as  contraction  is  present,  the  rectal 
bougie. 

The  Precautions. — Carefully  avoid  injury  of  the  vagina  in  the  female, 
and  of   the  urethra  in  the  male ;  notice  if  the  peritoneal  cavity  has  been 


1223, 


-Tlie  operation  of  perineal  proctectomy,  Alling- 
hain's  method. 


990  OPERATIVE   SURGERY. 

opened,  and  if  so,  repair  it  by  sewing,  if  possible,  otherwise  introduce  a 
gauze  tampon ;  with  care,  little  danger  from  tliis  involvement  need  be 
feared.  The  strong  tendency  of  the  opening  to  close  should  be  observed 
and  actively  combated  in  all  instances.  Retention  of  urine  is  likely  to  fol- 
low the  operation.  All  diseased  tissues  should  be  removed  if  practicable, 
otherwise  the  operation  will  be  of  but  little  use  and  possibly  do  much 
harm. 

The  lieinarks. — The  needless  sacrifice  of  any  part  of  the  rectum  or  anal 
margin  should  be  avoided  for  obvious  reasons.  When  the  growth  approaches 
the  posterior  wall  the  posterior  median  incision  should  be  made,  but  with  a 
due  regard  for  the  presence  of  the  superior  hsemorrhoidal  artery.  If  the 
disease  be  high  a  full  bladder  often  facilitates  the  operation  by  raising  the 
recto-vesical  pouch.  A  malignant  growth  within  the  rectum  of  the  male 
should  be  located  not  higher  than  four  inches  from  the  anus,  and  in  the 
female  not  higher  than  three  inches  anteriorly,  for  the  purposes  of  efficient 
removal  by  the  perineal  route.  The  prostate  body  and  contiguous  tissues 
are  slowly  invaded,  but  the  vagina  and  uterus  are  quite  promptly  involved 
by  malignant  extension  from  the  rectum.  The  suturing  of  the  end  of  the 
divided  gut  to  the  tissues  below  hastens  healing,  lessens  the  area  of  exposed 
raw  surface,  and  diminishes  the  tendency  to  stricture.  If  infection  happens 
above  the  line  of  sewing,  drainage  and  cleanliness  should  be  secured,  aided 
by  removal  of  one  or  more  and  perhaps  all  of  the  sutures.  Sutures  thus 
employed  should  be  carried  deeply  and  caused  to  eliminate  as  much  as  pos- 
sible the  presence  of  dead  spaces. 

The  Resultfi. — The  general  death  rate  of  the  operation  is  18  per  cent, 
and  about  15  per  cent  are  cured  (Wendel).  Special  operators  show  an  im- 
proved result  in  each  respect. 

Sacral  Proctectomy. — Sacral  proctectomy  is  a  procedure  devised  for  the 
purpose  of  high  removal  of  the  rectum  in  cases  not  amenable  to  operation 
by  other  routes."  For  briefness  and  lucidity  of  description  the  operation  is 
divided  into  three  stages :  1,  exposure  of  the  rectum  ;  2,  removal  of  the  dis- 
eased portion ;  3,  the  securement  of  the  upper  segment.  The  first  stage 
especially  is  variously  altered  by  different  operators,  all  of  which  changes  are, 
however,  but  modifications  of  the  original  conceptions  of  Kraske. 

Kraske's  Operation. — Administer  an  anesthetic,  and  place  the  patient 
on  the  right  side ;  make  an  incision  in  the  median  line  from  the  center  of 
the  sacrum  to  the  anus  through  the  soft  parts ;  detach  the  ligamentous  and 
fibrous  tissues  from  the  left  side  of  the  coccyx  and  the  sacrum  as  high  as  the 
third  sacral  foramen  ;  disarticulate  and  remove  the  coccyx,  and  with  a  gouge 
remove  the  lower  part  of  the  left  side  of  the  sacrum  in  a  curved  outline 
(Fig.  1224)  to  a  level  with  the  lower  border  of  the  third  sacral  foramen ;  free 
the  posterior  wall  of  the  gut  from  the  connective  tissue  and  muscles,  and 
place  the  patient  in  the  exaggerated  lithotomy  position ;  sever  the  anterior 
connections  of  the  bowel ;  isolate  carefully  the  parts  to  be  removed  with 
gauze  to  prevent  infection ;  remove  the  diseased  segment  by  transverse  divi- 
sion of  the  gut  at  a  distance  of  half  an  inch  or  so  at  either  side  of  the 
growth;  draw  the  bowel  down  from  above,  and  join  it  in  the  usual  manner 


Ol'KKA'l'loNS   ON    'rill',    ANTS    AND    inOC'I'lM. 


'.♦'.♦  1 


%,^^ 


''upper  HALF  or  FIFTH. 
POSTERIOR  SACRAL 
rOPAUCN. 


to   tlic   lower  sc<,Mnoiii   by  scwiiii; ;   cstahlisli    proiicr  ilruiiuigc,  and   prevent 
peritoneal  infection  hy  carct'iil  attention. 

The  })ret'e(lini,f  description  i.s  an  abl)reviat(Hl  statement  of  Kraske's  ])ioneer 
operations,  whieli,  while  rctainiiiif  merit,  have  yielded  to  the  modifying  influ- 
ences of  improved  teehnii|uc.     Tlie  incision  for  exposure  of  tlie  bcnvel  made  by 
Kraske  has  been  modiiietl  by 
various  surgeons  for  conserv- 
ative purposes  and  to  gain  ad- 
ditional room,    llocheiiefi;!  and 
Baden]iai(ei\  Levy,  Jk//i/i/f/icr 
(Fig.    1224),  and    others   re- 
moved an  additional  amount 
of  the  sacrum. 

Jleinecke  made  an  incision 
tlirough  the  sphincter  along 
the  middle  line  to  the  tip  of 
the  coccyx,  thus  exposing  and 
dealing  promptly  with  the  lirst 
part  of  the  rectum.  He  then 
extended  the  incision  along 
the  median  line  of  the  sacrum 
to  the  third  spine  of  that  bone, 
and  divided  the  bone  in  the 
course  of  the  incision  to  a 
point  corresponding  to  the 
lower  level  of  the  third  sacral 
foramen.  At  this  point  right- 
angled  incisions  were  made  at 
either  side  through  the  soft 
and  hard  parts,  and  the  tri- 
angular flaps  thus  formed  were 
turned  outward,  causing  free 
exposure  of  the  rectum. 

Kocher's  Method  of  Exposure  of  the  Rectum.— A'oc/^er  exposes  the  rectum 
at  the  left  of  the  gluteal  cleft  from  a  point  two  fingers'  breadths  below  the 
posterior  superior  iliac  spine  downward  to  and  along  the  median  line  of  the 
sacrum,  coccyx,  and  ischio-rectal  region  to  the  posterior  edge  of  the  anus, 
which  opening  it  surrounds,  terminating  at  the  rhaphe  in  front. 

If  bone  is  to  he  resected,  expose  the  edge  of  the  sacrum  by  separation 
from  the  bone  of  the  corresponding  part  of  the  gluteus  maximus ;  divide 
the  ligaments  and  muscles  attached  to  the  border,  and  separate  the  bone 
from  the  deeper  tissues ;  remove  respectively  the  coccyx,  the  lower  part  of 
the  sacrum,  or  a  small  portion  of  it,  or  a  piece  extending  up  to  the  fourth, 
the  third,  or  even  to  the  second  sacral  foramen,  as  may  be  needed  to  properly 
expose  the  bowel.  The  coccyx  is  removed  by  means  of  traction  made  by  a 
sharp  hook  applied  to  its  apex  during  its  disarticulation  ;  the  lower  part  of 
the  sacrum  by  chisel  and  mallet.     Active  bleeding  at  this  time  comes  from 


Fig.  1224. — The  operation  of  sacral  proctectomy,  ex- 
posure of  the  rectum,  a,  b.  c.  Kraske's  lines  of 
division  of  the  sacrum,  a,  c.  Hochenegg's  line 
of  division,  a,  d.  Badenhauer's,  Levy's,  and 
Rydygier's  lines  of  division. 


992  OPERATIVE   SURGERY. 

the  divided  bone,  find  the  middle  and  lateral  sacral  arteries.  The  arteries 
lie  so  closely  to  the  sacrum  that  ligature  is  difficult,  and  plugging  may  be 
required  to  arrest  bleeding.  The  inferior  hemorrhoidal  vessels  suffer  vi'ith 
division  of  the  sphincter  and  the  tissues  associated  with  the  anal  end  of  the 
rectum. 

If  bone  is  not  to  he  resected,  detach  the  greater  and  lesser  sacro-sciatic 
ligaments  from  the  edge  of  the  sacrum  and  both  edges  of  the  coccyx ;  divide 
the  pyriformis,  the  coccygeus,  the  levator  aui  below  the  apex  of  the  coccyx, 
and  the  external  sphincter,  from  above  downward. 

To  e.rpose  the  rectum  liiglter  up,  separate  its  connections  from  the  sacrum 
and  the  coccygeal  muscles  and  ligaments ;  divide  the  peritonaeum  at  either 
side  of  the  gut  at  the  j)osterior  wall  of  Douglas's  cul-de-sac  ;  ligature  branches 
of  the  middle  and  superior  ha3morrhoidal  arteries  during  higher  separation 
of  the  rectum;  divide  the  presacral  fascia;  draw  down  the  rectum  with  a 
blunt  hook  after  division  of  this  fascia,  and  ligature  the  lateral  and  posterior 
vessels ;  divide  the  prerectal  fascia,  thus  exposing  the  prostate,  vesiculae  semi- 
nales,  lower  ends  of  the  vasa  deferentia,  the  base  of  the  bladder,  and  the 
lower  end  of  the  ureter  a  little  to  the  outer  side  and  upper  end  of  the  vesic- 
ulaj  seminales. 

In  movable  carcinoma  of  the  rectum  within  the  reach  of  the  fincjer,  divide 
the  integument,  subcutaneous  tissue,  and  muscular  fibers  from  the  anus  to 
the  sacrum ;  free  the  rectum  laterally  by  passing  the  finger  along  either  side 
■of  the  gut,  hooking  np  and  cutting  between  ligatures  the  vascular  bands 
encountered ;  grasp  the  rectum  above  the  anus  and  pull  downward  upon  it, 
increasing  the  displacement  by  division  of  its  sacral  connections ;  draw  the 
growth  downward  and.  outward,  and  divide  the  muscular  coat  only,  an  inch 
or  an  inch  and  a  half  above  the  growth,  and  ligature  the  vessels ;  tie  a  strong 
silk  ligature  round  the  gut  above  the  point  of  division  of  the  muscular  coat, 
and  divide  the  mucous  membrane  below  the  incision  with  a  thermo-cautery ; 
separate  the  diseased  portion  with  the  mucous  membrane  downward  as  far 
as  the  anus,  and  remove  it,  using  care  to  prevent  infection ;  pull  down  and 
suture  tlie  tied  part  of  the  rectum  to  the  freshly  pared  muscular  margin  of 
the  anus.     Cleanse  the  lower  end  of  the  rectum  and  stuff  it  with  gauze. 

Tuttle  exposes  the  rectum  as  follows :  Place  the  patient  on  the  left  side 
with  hips  on  a  hard  pillow  in  Sims's  position,  and  with  the  legs  well  flexed  ; 
make  an  incision  at  the  left  side  about  half  an  inch  from  the  margin  of  the 
sacrum,  beginning  at  a  point  opposite  the  third  sacral  foramen  and  extending 
down  to  the  tip  of  the  coccyx ;  carry  the  incision  through  the  sacro-coccygeal 
ligament  into  the  cellular  tissue  behind  the  rectum  ;  detach  the  rectum  from 
the  anterior  wall  of  the  sacrum  with  the  fingers ;  make  a  transverse  incision 
at  the  upper  limit  of  the  first  incision  across  the  sacrum  down  to  the  bone ; 
divide  the  bone  transversely  with  a  chisel  and  turn  the  flap  to  the  left,  thus 
•exposing  to  view  the  rectum.  Tuttle  lays  stress  upon  the  control  of  haemor- 
rhage by  rapidly  exposing  the  rectum  and  clamping  it  with  a  long-jawed 
forceps  before  attempting  to  dissect  it  out. 

Levy's  Method  of  Exposure  of  the  Rectum.— Make  a  transverse  incision 
across  the  sacrum  a  finger's  breadth  above  the  cornua  of  the  coccyx  (Fig. 


orilKA'l'loNS   ON    Till':    ANIS    AND    IM'lC'lT.M. 


093 


ri'M)  down  to  the  hoiu',  and  extend  il  at,  eiLhcr  side  of  the  coccyx  in  a 
curved  direction,  pai-alUd  with  the  lihci's  of  tlio  gluteus  niaximus  to  williin 
two  inches  of  the  tuber  isciiii ;  sepai'ate  tiie  libers  of  tiie  gluteus  inaxiinus  at 
either  side  and  draw  them  ai)art;  locate  the  fourth  sacral  foramen;  exi)Ose 
and  divide  the  sacro-sciatic  ligaments  cand'ully  on  a  director  in  a  line  wiih 
the  original  incision  down  to  the  margin  of  the  sacrum  at  either  side ;  sepa- 
rate the  parts  in  front  of  the  sacrum  along  the  line  of  the  horizontal  inci- 
sion ;  introdnce  a  chain  saw  and  divide  the  bone  from  within  outward  ;  turn 
down  over  the  anus  the  osteoplastic  flap,  thereby  exposing  the  posterior 
rectal  region  to  view.     This  ])lan  is  not  regarded  with  special  favor. 

Rehii-Rydygier's  Method  of  Exposure  of  the  Rectum.— Make  an  incision 
from  the  posterior  superior  spine  of  the  ilium  downward,  along,  and  half  an 
inch  from  the  left  margin  of  the  sacrum  to  the  apex  of  the  coccyx,  thence 
along  the  median  line  to  near  the  anus  if  necessary  (Fig.  1225).  Expose  the 
margin  of  the 
sacrum    at    the 

upper  end  of  the  "^^^s^^--- 

incision ;   locate  ,-,-.'•'•"'      ""'■■-,, 

and   divide    the  // 

greater  and  less-  i'\  \ 

er  sacro-sciatic 
ligaments;  make 
a  transverse  in- 
cision across  the 
posterior  sur- 
face of  the  sa- 
crum two  fin- 
gers' breadth 
above  the  sacro- 
coccygeal artic- 
ulation ;  raise 
the  soft  parts 
from  the  anteri- 
or surface  of  the 
sacrum       below 

the  third  sacral  foramen  ;  saw  or  chisel  through  the  sacrum  transversely  in 
the  line  of  the  incision;  turn  the  osteocutaneous  flap  to  the  right,  and 
expose  the  posterior  rectal  region.  This  plan  is  regarded  with  special 
favor. 

Borelius's  Method  of  Exposure  of  the  Rectum.— Place  the  patient  on  the 
right  side  with  the  knees  drawn  up  and  the  pelvis  raised.  Make  an  incision 
in  the  median  line  from  the  tip  of  the  coccyx  to  a  little  above  the  middle  of 
the  sacrum  down  to  the  bone ;  make  a  second  incision  from  the  beginning  of 
the  first  along  the  lower  border  of  the  left  gluteus  maximus  muscle  ;  separate 
the  flap  from  the  sacrum  and  draw  it  aside ;  raise  the  tissues  of  the  right 
border  of  the  wound  sufficiently  to  permit  the  division  of  the  sacrum  ob- 
liquely downward  from  left  to  right  below  the  third  (left)  and  fourth  (right) 


Fig.  1225. — The  operation  of  sacral  proctectomy,  a.  Posleriijr  supe- 
rior spine  of  ilium,  b,  c.  Transverse  incision,  c,  d.  Incision  at 
left  border  of  sacrum,  etc. 


99-i  OPERATIVE   SURGERY. 

sacral  foramen ;  free  the  bone  flap  sufticiently  to  permit  it  to  be  turned  to 
the  left,  thus  exposing  to  view  the  posterior  rectal  region. 

The  Remarks. — Since  the  third  sacral  nerves  are  concerned  largely  in  the 
motor  function  of  the  rectum  and  bladder,  it  is  unwise  to  invade  the  third 
sacral  foramen  needlessly,  as  paralysis  of  these  viscera  may  result  from  injury 
to  the  nerves.  However,  Kocher  states  that  the  division  of  the  sacrum  may 
be  extended  up  on  one  side  as  far  as  the  second  sacral  foramen  without  per- 
manent loss  of  power  of  the  rectum  and  bladder,  because  of  the  integrity  of 
the  nerves  of  the  opposite  side.  General  practice  commends  the  exposure  of 
the  third  and  fourth  sacral  foramen,  the  drawing  aside  of  the  corresponding 
nerves,  and  transverse  division  of  the  sacrum  just  below  the  third  sacral 
foramen.  An  oblique  section  of  the  sacrum  of  proper  dimensions  removes 
in  any  instance  the  fourth  sacral  foramen.  The  division  of  the  sacro- 
sciatic  ligaments  at  the  border  of  the  sacrum  exposes  to  danger  the  pudic 
vessels  and  nerves.  In  no  instance  should  the  bone  flap  be  replaced  and 
fastened  in  position  unless  proper  union  of  the  divided  bow^el  is  assured. 
The  normal  support  given  the  rectum  and  pelvic  contents  by  the  sacrum  is 
not  much  impaired  if  the  bone  flap  be  restored  to  its  normal  relations  with 
the  contiguous  tissues.  Operations  that  limit  the  extent  of  the  bone  excision 
to  a  minimum  limit  likewise  the  opportunity  of  inspection  and  manipula- 
tion of  the  diseased  part,  which  are  of  greater  significance  than  is  the  dimin- 
ished support  incident  to  liberal  resection. 

The  Second  Stage  {Removed  of  the  Diseased  Portion). — The  rectum  is 
dissociated  from  surrounding  tissues  by  means  of  blunt  dissection  with  the 
fingers,  grooved  director,  blunt-pointed  scissors,  etc.,  attended  by  prompt 
arrest  of  hasmorrhage  by  ligature  and  gauze  packing.  If  the  peritoneal 
cavity  be  opened  into  inadvertently  or  otherwise,  the  wound  is  promptly 
closed  by  suture  or  tamponade,  depending  on  the  reason  for  the  infliction  of 
the  injury  and  the  jaresence  of  infecting  agencies.  Careful  protection  with 
gauze  should  be  given  the  peritonaeum  and  other  tissues  during  removal  of 
the  diseased  part.  The  limits  of  the  disease  are  determined  by  external  ma- 
nipulation of  the  bowel,  or,  if  need  be,  internal  digital  examination  conducted 
through  an  opening  made  into  the  gut  near  the  locality  of  the  disease.  The 
diseased  part  is  removed  by  use  of  the  scissors,  cautery,  etc.  The  removal 
of  the  diseased  segment  is  followed  quickly  by  cleansing  of  the  wound  and 
closure  of  the  peritoneal  openings  by  sewing  when  possible.  The  bringing 
down  to  the  proper  position  for  union  of  the  upper  segment,  especially  in 
high  division,  must  be  so  conducted  as  not  to  impair  the  nutrient  vessels  of 
the  mesentery  and  cause  gangrene  of  the  gut.  Gerster  emphasizes  the 
importance  of  cautious  technique  in  the  following  well-chosen  words : 
"Where  high  amputation  is  to  be  performed,  the  surgeon  must  try  sedu- 
lously to  preserve  the  nutrient  vessels  of  the  mesentery,  otherwise  the  entire 
rectal  stump  may  mortify.  This  will  be  found  most  difficult  in  that  part  of 
the  rectum  which  adjoins  the  flexure.  Lateral  incisions  through  the  peri- 
toneal attachments  are  permissible,  but  cutting  into  the  mesenteric  line 
itself  will  certainly  be  followed  by  disaster.  Adequate  lateral  incisions  will 
permit  the  surgeon  to  peel  up  the  gut  from  the  sacrum  by  the  gentle  use  of 


OPERATIONS   ON   TIIK    ANUS   AND    RKCTUM.  995 

the  liii<,^L'r  tij).  Tlu'  lii^^flu-r  lliis  (k'tuclmiciit  of  the  <i;ut  is  carried  ii]),  the 
less  tension  will  have  to  he  encountered  in  drawing  down  and  attaching  the 
stump  to  the  upper  angle  of  tlie  external  incision,  especially  where  portions 
of  the  sacrum  have  heen  removed.  A  few  stout  silk  sutures  passed  through 
the  entire  thickness  of  the  gut  laterally  will  serve  ani])ly  to  anchor  the  gut 
to  the  skin,  the  seat  of  the  wound  remaining  open.  In  cases  where  the 
peritoneal  cavity  has  been  invaded,  it  is  best  to  stitch  up  carefully  the  peri- 
toneal wound  as  soon  as  possible."  Incautious  manipulation  of  the  rectum, 
especially  traction,  exposes  the  i)atient  to  all  the  dangers  attendant  on  con- 
sequent rupture.  Tuttle  emphasizes  the  importance  of  cutting  the  meso- 
rectum  as  close  to  the  sacrum  as  possible,  in  order  to  avoid  wounding  the 
superior  hemorrhoidal  artery,  lie  considers  that  the  most  important  part 
of  the  technique  is  dissecting  out  and  bringing  down  all  of  the  intestine  that 
is  intended  for  removal,  and  closing  the  peritoneal  cavity  thoroughly  by 
sutures  or  packing  before  opening  the  gut  at  all,  thus  avoiding  infection 
of  the  abdominal  cavity,  whicli  he  regards  as  the  greatest  danger  in  the 
operation. 

The  Third  Stage  {Securement  of  the  rj^jyei'  Seynie)ii). — Before  the  final 
division  is  made,  the  upper  end  should  be  securely  held  to  prevent  its 
escape  from  the  operator.  It  is  then  drawn  down  and  fastened  to  the  anal 
portion  without  tension  by  circular  enterorrhaphy,  Murphy's  button,  lateral 
implantation  method,  etc.  When  completely  closed  by  sewing,  faecal  fistulae 
follow  not  infrequently  at  the  posterior  surface  of  the  gut,  due  to  the  tearing 
out  of  the  stitches  at  that  point.  However,  division  of  the  sphincter  (Czerny) 
and  inguinal  colostomy  (Schede)  are  practiced  with  success  in  the  prevention 
of  fistuhe  in  the  cases  of  contemplated  union  by  sewing.  The  final  integrity 
of  the  normal  sphincter  is  essential  to  the  best  outcome ;  therefore,  disease 
of  this  portion  of  the  bowel  is  especially  burdensome.  If  a  healthy  sphinc- 
teric  area  be  present,  and  the  stump  be  of  sufficient  length  to  permit  it  to  be 
drawn  through  the  lower  segment  within  the  control  of  the  sphincter,  and 
stitched  to  the  integument  outside  the  anus,  increased  control  of  the  opening 
is  secured  (Hochenegg).  The  removal  of  the  mucous  lining  of  the  lower 
part,  and  freshening  the  anus,  aid  repair.  Morestiu^  believing  resection 
usually  causes  final  paralysis  of  sphincter,  removes  the  gut. 

Lange  successfully  approximated  the  lower  to  a  too  short  upper  segment 
in  the  following  manner :  After  resection  of  the  diseased  area  and  failure  of 
suitable  approximation,  he  secured  upward  displacement  of  the  lower  seg- 
ment througli  the  agency  of  a  curved  incision  extending  between  the  tuber 
ischii  in  front  of  the  anus,  and  going  down  to  and  dividing  some  of  the 
anterior  fibers  of  the  levator  ani.  Upward  pressure  on  the  flap  thus  formed 
caused  a  gain  of  two  inches  or  so  in  aid  of  the  approximation  of  the  seg- 
ments. Two  cases  are  reported  as  treated  by  this  method,  in  both  of  which 
satisfactory  sphincteric  action  occurred  only  in  the  presence  of  solid  faeces. 

Vicarious  Sphincteric  Control. — The  possibility  of  vicarious  or  normal 
control  of  the  end  of  the  bowel  is  a  very  important  element  of  comfort  and 
satisfaction  to  the  patient  and  friends  in  determining  whether  or  not  to  sub- 
mit to  operative  procedure  that  contemplates  the  loss  of  the  control  of  faecal 
G9 


996 


OPERATIVE   SURGERY. 


discharge.  In  this  connection  it  should  be  noted  that  ffecal  incontinence 
does  not  solely  depend  on  the  integrity  of  the  sphincters,  but  also  on  that  of 
the  functions  of  the  mucous  membrane  of  the  points  of  exit.  Thus,  wlien 
the  lower  end  of  the  rectum  is  removed  and  the  proximal  extremity  sewed 
to  the  integumentary  border,  this  extremity  is  not  possessed  of  the  inhibitory 
power  of  the  antecedent  part,  and  therefore  temporary  incontinence  may 
result,  which  later  disappears,  in  most  instances,  when  the  divided  nerve 
connections  are  re-established.  In  the  instance  of  proctectomy  the  follow- 
ing expedients  for  better  control  are  sometimes  practiced.  Carrying  the  end 
of  the  rectum  between  the  fibers  of  the  gluteus  maximus  at  the  lower  or 
upper  part,  as  may  best  suit  the  length  of  the  upper  segment,  is  an  ingenious 
measure  devised  by  Wtllei)ts  and  others,  and  can  be  commended  as  a  harmless 
effort  that  has  been  followed  with  beneficent  results  on  several  occasions ; 
in  certain  cases  the  utilization  of  the  pyriformis  for  the  purpose  is  com- 
mended. 

Gersuny  practiced  torsion  of  a  limited  part  of  the  upper  segment  between 
two  forceps,  until  appreciable  resistance  attended  the  introduction  of  the 
index  finger,  then  stitched  the  end  to  the  skin  margin,  thus  securing  some 
retentive  power  at  the  lower  end.  Successful  instances  are  cited  of  this 
method. 

In  connection  with  artificial  anus  various  measures  of  control  of  the 
faecal  discharge  have  been  devised,  such  as  the  drawing  of  the  bowel  through 
a  vertical  separation  of  the  fibers  of  the  outer  edge  of  the  rectus  abdominis 
(Ilowse),  and  through  a  vertical  and  oblique  division  (von  Hacker)  at  some 


Fig.  1226. — Operation  for  vicarious  sphinc-  Fig.  1227. — Operation  for  vicarious  sphinc- 

teric  control,    a.  Loop  of  intestine.    6.  c.  teric  control.  Braun's  method,      a.  a. 

Opening  in  abdomen,     d,  e.  Opening  at  Proximal  end  of  sigmoid  and  vicari- 

anterior   surface   of    thigh  (Braun)  for  ouso|)cning.    J.  Rectal  end  of  sigmoid 

escape  of  intestine  along  channel  limited  closed  and  dropped  back  into  pelvis, 

by /,  rf,  ^,  and  e.  e, /.  Abdominal  opening,     c,  d.  Anal 

opening. 

distance  above  the  pubis,  or  through  a  vertical  incision  of  the  rectus  imme- 
diately above  that  bone,  supplemented  by  gouging  of  its  upper  border  to 
provide  a  completer  outlet  (Roux).  The  separation  (Maydl),  instead  of 
division  of  the  muscular  fibers,  attended  with  stitching  together  of  the  arms 


OPKKA'rioNS   (IN    TlIK   ANTS   AND    KECTIM. 


997 


'■'I 


teric  control,  Witzel's  method.  «. 
Proximal  end  of  sigmoid,  h.  Rectal 
end  closed  and  dropped  back  into  pel- 
vis, e,  /.  Abdominal  opening,  c,  d. 
Vicarious  opening,  sigmoid  passing 
across  crest  of  ilium. 


of  the  loop,  art'  iriiportaiit  features  of  .successful  outcorue  in  these  eases.  The 
removal  of  tlie  loop  of  intestine  (Fig.  I'-i'-iO),  the  closure  and  dropping  back 
of  the  rectal  end  into  the  pelvis  (Fig.  Vl'll)^  followed  by  transference  be- 
neath the  skin  of  the  upper  end  to  a  point  below  the  crest  of  the  ilium 
(Wit/.el),  with  or  without  narrowing  of 
the  end  of  the  bowel,  is  admirable  prac- 
tice (Fig.  ITl^). 

MaunseWs  method  of  enterorrhaphy 
can  be  practiced  after  tiie  removal  of 
the  growth  at  the  junction  of  the  sig- 
moid and  rectum,  or  in  the  event  of 
recto  -  sigmoidal  intussusception.  It 
will  not  be  amiss  to  emphasize  the  im- 
portance of  the  measure  in  the  latter 
condition  by  reference  to  the  illustra- 
tive case  reported  by  Hartley. 

"Tiie  tumor  was  exposed  through 
a  liberal  median  incision  with  the  pa-  :^  , 

tient  in  Trendelenburg's  position,  and  Fig.  1228.1operation  for  vicarious  sphinc- 
raised  upward  out  of  the  pelvis  as  far 
as  possible,  and  surrounded  with  gauze. 
An  incision  three  inches  in  length  was 
made  over  the  lower  segment  entering 
the  intestine  —  intussuscipiens  (Figs. 
906  and  910) ;  the  tumor  and  intussusceptum  were  delivered  through  this 
opening  after  protecting  the  mass  with  additional  gauze.  The  intussuscep- 
tum was  then  divided  transversely  a  little  below  its  neck.  The  divided 
ends  were  held  in  position  until  the  arteries  in  the  mesenteric  border  were 
securely  ligated.  Silk  sutures  were  then  passed  through  all  the  coats  of 
the  intestines  as  they  were  held  in  position,  according  to  Maunsell's  recom- 
mendation, and  tied  (Fig.  908). 

"  One  or  two  catgut  ligatures  were  placed  in  the  mucous  membrane  along 
where  it  gaped.  The  fold  was  then  reduced,  and  a  Lembert  suture  was  car- 
ried around  the  intestine  above  the  larger  and  deeper  sutures.  After  this, 
the  longitudinal  incision  in  the  lower  segment  was  sutured  by  a  few  stitches 
of  silk  in  the  mucous  membrane,  and  a  Lembert  suture  in  the  serosa  and 
submucosa.  The  cavity  was  wiped  out  with  a  sponge.  The  abdominal 
incision  was  closed  with  silkworm  gut."  The  recovery  in  this  case  was 
prompt  and  uneventful. 

Murphy's  button  can  be  made  to  exercise  an  important  function  in 
suitable  cases  of  resection  of  the  rectum.  It  should  not  be  regarded,  how- 
ever, as  a  suitable  substitute  for  the  Kraske  method  of  practice  only  in  excep- 
tional instances.  It  is  employed  in  the  following  manner :  Dilate  the 
sphincter  widely ;  draw  down  with  forceps  the  diseased  process ;  insert  in 
an  out-and-in  manner  through  the  wall  of  the  bowel  below  the  disease  the 
puckering  string ;  divide  tlie  bowel  transversely  a  quarter  of  an  inch  above 
the  string ;  seize  the  proximal  segment  with  forceps  and  draw  it  down  into 


998  OPERATIVE   SURGERY. 

the  distal,  while  separation  above  is  being  made  with  the  fingers ;  insert  half 
an  inch  above  the  disease  another  puckering  string  and  divide  the  rectum 
half  an  inch  below  it,  thus  removing  the  disease  ;  introduce  the  male  portion 
of  the  button  into  the  upper  segment,  and  fasten  it  in  place  with  its  pucker- 
ing string,  which  is  then  cut  short;  pass  the  female  portion  of  the  button 
up  over  the  distal  string  until  it  catches  the  end  of  the  male  cylinder  suffi- 
ciently to  hold  it  in  place ;  make  a  small  parallel  incision  into  the  lower 
seo-ment  of  the  rectum  over  the  coccyx  and  half  an  inch  below  the  first 
puckering  string ;  pass  through  the  opening  a  strand  of  iodoform  gauze 
for  drainage,  allowing  it  to  remain  in  place  for  three  or  four  days;  draw  the 
button  into  the  distal  end,  confine  it  with  the  puckering  string,  which  is  cut 
short,  and  the  segments  of  the  button  are  then  approximated.  The  bowels 
are  kept  loose  during  the  presence  of  the  button  in  the  rectum.  The  but- 
ton may  be  expected  to  come  away  on  the  tenth  or  twelfth  day.  The  im- 
possibility in  many  instances  of  removing  all  the  disease,  the  limited  space 
of  action,  and  the  difficulty  in  securing  proper  adjustment  of  the  seg- 
ments of  the  button  are  among  the  obstacles  that  unfit  the  appliance  for 
general  use. 

The  Geueral  Remarks. —  Quenu,  through  a  low  colostomy,  carried  a  solid 
sound,  grooved  at  the  end,  down  to  within  an  inch  of  the  growtli.  ligatured  the 
bowel  firmly  in  the  groove,  divided  the  gut,  and  slowly  withdrawing  the  sound 
invaginated  the  rectum  and  fastened  it  to  the  wound  above.  When  this  can 
not  be  done  a  sacral  anus  is  made.  Keen,  after  a  preliminary  colostomy,  sewed 
up  and  dropped  back  into  the  abdomen  the  cut  end  of  the  rectum.  Sphincteric 
relaxation  by  division  or  stretching  should  be  done  in  all  cases  of  extended  dis- 
ease, the  latter  is  never  amiss  in  enterorrhaphy  or  union  by  theMurphy  button  as 
a  preventive  measure  of  fistula.  The  hn^morrhoidal  branches  of  the  gut  lie  so 
closely  in  contact  with  the  muscular  wall  that  they  are  readily  displaced  along 
with  the  bowel,  and  for  this  reason  are  not  injured  if  the  mesocolon  be  divided 
close  to  the  sacrum.  The  division  at  either  side  of  the  bowel  of  the  perito- 
neum which  holds  it  in  place  should  be  carefully  practiced  with  scissors,  to 
prevent  injury  of  the  contiguous  vessels  and  obviate  the  danger  of  necrosis 
of  the  stump.  The  extent  of  the  peritoneal  division  will  be  governed  by  the 
heio"ht  of  the  growth  in  the  bowel,  and  the  degree  of  downward  displacement 
required  to  secure  proper  adjustment  of  the  stump  without  tension;  if  the 
disease  be  too  extensive  for  removal  the  bone  flap  should  be  replaced  and 
fixed  in  position.  Careful  enucleation  of  the  disease  should  be  practiced,  as 
perforation,  infection,  and  free  bleeding  will  otherwise  be  caused,  and  after 
enucleation  the  closure  of  peritoneal  wounds  by  sewing  or  gauze  should  be 
promptly  made.  Two  iodoformized  gauze  ligatures  may  be  carried  around 
the  bowel  about  an  inch  above  the  growth,  the  intestine  severed  between 
them  with  scissors,  and  the  divided  ends  cleansed  and  wrapped  in  gauze,  to 
prevent  infection.  Quenu  and  Hartmann  regard  free  and  easy  access  to  the 
rectum  and  absolute  asepsis  as  necessary  to  the  attainment  of  the  highest 
outcome.  They  advise  that  the  process  be  isolated  by  means  of  elastic  liga- 
tures passed  around  the  gut  above  and  below  the  seat  of  the  disease,  and  that, 
after  making  a  circular  incision  around  the  anus,  the  anal  opening  be  closed 


OI'KIIATIONS   ON   THE   ANUS   AND    UKCTUM.  <)<)*) 

by  sewing  and  cautery  applied  to  it  for  greater  safety.  The  introduction  of 
tiie  finger  into  a  cleansed  rectum  during  operation  is  earnestly  opj)osed  by 
these  authorities.  In  instances  of  recto-sigmoid  involvement  Quenu  and 
llartmann  recommend  closure  of  the  anus,  abdominal  section,  removal  of  the 
rectum,  and  tiie  establishment  of  artificial  anus  in  the  abdominal  wound. 
Kraske,  of  FrciWurg,  through  an  abdominal  incision  ties  and  severs  the 
superior  luvmorrhoidal  artery  between  two  ligatures,  then  divides  and  sepa- 
rates the  rectal  peritonaeum,  removing  the  enlarged  lymphatic  nodes  in  meso- 
colon and  mesorectum  without  loss  of  blood.  The  anus  should  be  placed  in 
the  sacral  wound,  if  tension  be  too  great  to  permit  proper  adjustment  else- 
where of  tiie  upper  segment,  and  libenil  release  above  of  the  rectum  should 
be  made  before  union  below  is  attempted.  The  wound  should  be  packed 
with  gauze,  wdiich  is  ci)anged  within  forty-eight  hours  if  faecal  escape  be 
feared.  In  any  instance  it  is  dressed  afterward  as  often  as  cleanliness 
demands.  When  granulation  becomes  well  established,  the  patient  can  be 
up  and  around,  and  thus  get  the  benefit  of  fresh  air  and  returning  confi- 
dence. In  the  instance  of  an  anus  of  defective  retaining  force,  a  close- 
fitting  pad  should  be  worn. 

llie  Choice  of  Operation. — Cancer  of  tlie  rectum,  like  similar  growths 
elsewhere  in  the  body,  may  be  treated  radically  whenever  it  is  technically 
possible  to  remove  the  disease  and  the  patient's  condition  warrants  the  at- 
tempt. The  fact  of  contiguous  involvement  need  not  contraindicate  the 
attempt,  provided  the  preceding  indications  are  available.  The  perineal 
method  is  suitable  in  those  cases  in  which  the  disease  is  within  easy  reach, 
well  defined,  and  the  lumen  of  the  gut  amenable  to  proper  control.  Para- 
sacral incision,  with  removal  of  the  coccyx  and  perhaps  without,  affords 
ample  room  for  the  employment  of  the  perineal  method.  Those  cases  in 
which  the  disease  is  located  higher  up  than  for  the  preceding  method  of 
attack  are  suitable  for  approach  by  the  sacral  route.  Kr'Onlein  believes  that 
the  sacral  route  of  approach  should  be  reserved  for  removal  of  disease  of  the 
upper  part  of  the  rectum.  Mathews  regards  the  sacral  route  as  dangerous, 
difficult,  and  unpromising.  Many  English  surgeons  share  in  this  opinion, 
and  limit  their  efforts  to  the  availability  of  the  perineal  operation. 

The  Results. — Incontinence  of  faeces,  fistula,  stricture,  and  prolapse  con- 
stitute the  j^rominent  sequels  of  the  operation.  If  the  sphincter  be  removed 
and  the  levator  ani  be  greatly  impaired,  but  little  control  will  be  had  of  the 
intestinal  contents.  However,  the  command  is  better  if  the  bowel  be  not, 
than  if  it  be,  sutured  to  the  skin  under  these  circumstances,  as  in  the  former 
method  greater  cicatricial  change  will  take  place.  It  appears,  so  far  as  def- 
initely stated,  that  complete  incontinence  of  faeces  happens  in  about  6  per 
cent,  partial  in  about  9,  and  satisfactory  control  in  the  remainder  of  the 
cases.  Fistula  results  from  imperfect  union  dependent  on  tension,  defective 
sewing,  infection,  etc.  Many  fistula?  heal  quite  promptly  with  the  use  of 
bougies  and  proper  cleanliness ;  others  require  special  operation  for  cure. 
Stricture:  Every  form  of  union  of  the  segments  is  (1  in  10)  liable  to  be  fol- 
lowed by  stricture  at  the  seat  of  junction.  The  knowledge  of  this  liability 
should  be  forestalled  by  frequent  inspection  and  a  discreet  use  of  bougies. 


1000  OPERATIVE  SURGERY. 

Prolapse  of  the  rectum  (rare  before  Kraske's  method)  is  the  outcome  com- 
monly of  impairment  of  the  sacral  floor ;  therefore  the  importance  of  this 
defect  should  be  heeded  and  the  meso-rectum  should  be  thoroughly  repaired. 
The  general  death  rate  of  the  sacral  method  of  operation  is  from  18  to  25 
per  cent.  The  final  outlook  in  highly  favorable  cases  is  gratifying,  as  ?5 
per  cent  of  Kocher's  operative  recoveries  were  alive  and  well  four  to  sixteen 
years  after  operation ;  (j2  per  cent  of  Czerny's  cases  were  free  from  disease 
when  reported,  a  third  of  which  were  of  two  years'  standing.  Hoclienegg 
reports  the  operation  mortality  in  his  cases  at  8.2  per  cent,  and  the  cure  at 
25  per  cent.  He  no  longer  operates  for  recurrence.  Kr'dnlein  has  collected 
881  cases,  from  German  sources,  of  extirpation  of  the  rectum  by  the  radical 
method,  showing  a  rate  of  mortality  of  20  per  cent  and  cure  of  1-4.30  per 
cent.  He  concludes  that  the  best  functional  results  follow  when  the  proxi- 
mal end  of  the  gut  is  caused  to  occupy  the  normal  site  of  the  anus,  and  when 
the  sphincters  are  preserved ;  also  that  the  removal  of  all  the  rectal  struc- 
tures does  not  increase  the  rate  of  permanent  cure  and  is  followed  by  the 
worst  of  functional  results. 

In  Titttle's  late  and  exhaustive  paper  appears  the  following  instructive 
facts  bearing  on  this  topic,  based  on  the  results  in  about  GOO  cases  here  and 
abroad  : 

finet's  syxopsis  of  cases. 

Immediate  deaths 66 

Deaths  under  1  year,  cause  not  given,  8 ;  deaths  between  1  and  2  years,  3 ; 

deaths  between  2  and  3  years,  1 12 

Deaths  from  recurrence  in  situ,  under  1  year,  17;  metastasis  under  1  year, 
12 ;  in  situ,  between  1  and  2  years,  2 ;  metastasis  between  1  and  2 
years,  1 ;  iti  situ,  between  2  and  3  years,  3 ;  metastasis  between  2  and 
3  years,  1 36 

Living  with  recurrence  under  1  year,  18 ;  under  2  years,  1 ;  under  3  years, 

1 ;  over  3  years,  2 22 

Living  without  recurrence  under  1  year,  124;  under  2  years,  11;  3  years. 
23 ;  4  to  5  years,  10 ;  5  to  6  years,  7 ;  6  to  7  years,  6 ;  7  to  8  years,  5 ;  8 
to  10  years,  5;  10  to  11  years,  3;  11  to  12  years,  1 ;  12  to  14  years,  1 : 
14  to  15  years,  2 ;  15  to  16  years,  1 ;  over  16  years,  2 201 

Died  without  recurrence  after  4  years,  4 4 

Mortality,  19  per  cent 341 

tuttle's  syxopsis  of  cases. 

Immediate  deaths 31 

Deaths  under  1  year,  recurrence  in  situ,  8 ;  by  metastasis,  6 ;  between  1  and 
2  years,  recurrence  in  situ,  4 ;  by  metastasis,  3 ;  between  2  and  3  years, 
recurrence  iti  situ,  4 ;  by  metastasis,  2  ;  after  3  years,  recurrence  in  situ, 
none ;  by  metastasis,  1 28 

Living  with  recurrence  under  1  year.  6 ;  between  1  and  2  years,  5 ;  1  each 

2,  4,  2,  2,  2^,  4  years 17 

Living  without  recurrence  under  1  year,  90;  over  1  and  under  2  years.  48: 

over  2  and  under  3  years,  20 ;  over  3  years,  23 181 

Mortality,  11.7  per  cent 257 

Sacral,  173  cases,  23  deaths;  mortality,  13.3  per  cent.  Perineal,  70  cases,  5  deaths; 
mortality,  7.1  per  cent.     Vaginal,  1  death ;  anal,  1  death ;  not  given,  1  death. 


OI'KKATIUNS  UN   THE   ANUS   AND   RKCTUM. 


lool 


Colorectostomy. — Colorectostomy  can  be  practiced  at  the  lower  part  of 
tlie  sigmoid  llexure  througli  a  median  abdominal  or  the  sacral  incision.  Jn 
the  foniicr  method  paralyze  the  sj)hiii(aer  by  overdisteution,  and  wash  out 
the  rectum  ;  ])lace  tlie  ])atient  in  'J'rendelenburg's  position,  and  make  an 
abdominal  incision  in  the  median  line  from  the  symphysis  to  the  navel; 
excise  the  growth,  if  feasible,  and  close  the  distal  end  of  the  gut  with  su- 
tures. If  excision  be  not  feasible,  divide  the  colon  above  the  growth  and 
close  the  distal  end  as  before ;  pass  through  the  borders  of  the  open  proxi- 
mal end  six  strong,  silk  traction  sutures,  leaving  the  ends  of  each  suture  not 
less  than  ten  inches  in 
length ;  thrust  through 
the  anus  up  the  rectum 
along  its  anterior  wall 
to  within  two  inches  of 
the  growth,  or  against 
the  closed  end  (if  the 
growth  have  been  re- 
moved), a  long-handled 
forceps  or  a  sponge 
holder ;  make  an  inci- 
sion an  inch  in  length 
at  the  peritoneal  aspect 
of  the  rectum  down 
upon  the  instrument 
with  a  bistoury;  pass 
the  forceps  through  the 
opening  and  seize  the 
twisted  bundle  of  trac- 
tion sutures ;  withdraw 
the  forceps  with  the 
sutures  from  the  bowel, 
and  by  gentle  traction 
cause  the  "  telescop- 
ing "  of  the  upper  seg- 
ment into  the  lateral 
incision  of  the  lower 
the  desired  distance, 
which    should   be   not 


Fig.  1229. — The  operation  of  colorectostomy.  Removal  of 
the  upper  part  of  the  rectum,  with  the  uterus,  tubes,  and 
ovaries.  The  union  of  sigmoid  and  rectum  should  be 
made  by  sero-serous  sutures. 


less  than  half  an  inch ;  unite  with  sutures  at  the  pelvic  side  the  infolded 
serous  surface  of  the  lower  segment  with  the  serous  covering  of  the  upper, 
if  possible,  holding  the  parts  firmly  by  the  traction  sntures  during  the  sew- 
ing (Fig.  1229).  Wash  out  the  pelvis  with  a  warm  saline  solution,  and  ad- 
just strips  of  iodoform  gauze  packing  around  the  colorectal  junction,  allow- 
ing the  ends  to  escape  from  the  lower  angle  of  the  abdominal  wound,  the 
remaining  portion  of  which  is  closed  ;  if  no  evidence  of  fsecal  leakage  be 
seen  at  the  end  of  four  or  five  days,  withdraw  the  gauze  and  close  the 
wound  almost  entirely. 


1002  OPERATIVE   SURGERY. 

Sacral  colorectostomy  is  quite  readily  done  after  reflection  of  the  osteo- 
cutaneous liaps,  in  the  same  manner  as  with  the  median  incision  (Uhlmann). 
It  has  been  suggested,  in  order  to  obviate  tlie  rectal  obstruction  and  the  for- 
mation of  an  artificial  anus,  through  a  median  incision,  to  stitch  a  loop  of  sig- 
moid to  the  rectum  below  the  seat  of  the  disease,  and  make  an  opening  at  the 
site  of  union  by  way  of  the  rectum,  after  adhesion  has  taken  place  (Bacon). 

Vaginal  Proctectomy. — The  approach  to  the  rectum  through  the  vagina 
has  a  limited  and  as  yet  undeveloped  availability.  After  the  usual  antiseptic 
preparatory  treatment  of  the  rectum,  vagina,  and  cervix  uteri,  empty  the 
bladder  and  tampon  the  rectum ;  make  an  incision  in  the  posterior  wall 
of  the  vagina  from  the  cervix  to  the  perina-um  down  to  the  sphincter  and 
levator  ani  fibers;  separate  the  rectum  from  below  upward,  and  draw  it  for- 
ward at  the  same  time  ;  arrest  haemorrhage,  and  remove  the  necessary  portion 
of  the  gut,  as  already  described  ;  draw  the  bowel  down  and  stitch  it  to  the 
borders  of  the  wound  in  the  usual  manner;  close  the  vaginal  wound  with 
sutures,  and  apply  gentle  coaptation  compression  to  the  seat  of  operation  by 
vaginal  tampon.  Heydenreich  believes  that  this  route  should  be  limited  to 
those  cases  in  which  the  vagina  is  not  impaired  at  the  point  of  division,  and 
in  which  the  disease  is  limited  to  the  lower  four  or  five  inches  of  the  bowel. 
He  extends  the  incision  to  the  coccyx,  thereby  forming  two  posterior  flaps. 
Heydenreich  claims  that  less  shock  and  less  liability  to  fistula  and  faecal 
incontinence  attend  this  than  the  sacral  method.  Reliyi  commends  the 
method,  practiced  singly  or  with  abdominal  incision. 

The  Results. — Eleven  successful  cases  and  one  death  by  this  method  are 
reported. 

Murjiliy  reports*  five  comparatively  late  cases  of  his  own  of  resection  of 
the  rectum  -per  vaginam.  After  describing  the  steps  of  the  operation,  he 
states  its  advantages  as  follows  : 

"  1.  The  sacrum  and  posterior  bony  wall  of  the  pelvis  are  not  disturbed. 

"2.  The  field  of  operation  is  as  extensive  and  the  anatomical  parts  as 
accessible  as  in  the  trans-sacral  operations. 

"  3.  The  peritoneal  cavity  is  opened  in  both  the  vaginal  and  sacral  opera- 
tions, and  in  neither  is  it  a  source  of  great  danger. 

"4.  The  diseased  tissue  is  more  accessible  for  inspection,  and  the  extent 
to  which  the  operation  may  be  carried  in  an  upward  direction  is  as  great,  if 
not  greater,  than  by  the  sacral  route. 

"  5.  The  peritongeum  may  be  drained  freely  through  the  vagina. 

"  6.  A  perfect  end-to-end  approximation,  either  by  suture  or  by  the  use 
of  the  button,  may  be  secured.  The  preferable  method  of  uniting  the  two 
ends  is  by  interrupted  sutures  of  silk,  because,  as  there  is  no  peritona:'um  on 
the  sphincteric  segment,  failure  of  union  with  the  button  is  to  be  feared. 

"  7.  The  sphincter  is  retained  and  the  perineal  body  is  restored.  There 
is  diminished  action  of  the  levator  ani  muscle. 

"8.  When  the  operation  is  complete  the  parts  are  practically  in  their 
normal  positions." 

*  Philadelphia  Medical  .Journal,  Febrviary  23,  1901. 


CHAPTER    XVI. 
OPERATIONS  ON   THE  THORAX. 

Excision  of  the  Breast. — The  excision  of  the  female  breast  for  the  cure 
of  malignant  tumor  of  the  organ  is  for  many  reasons  quite  as  conspicuous 
a  procedure  from  the  lay  standpoint  as  belongs  to  the  field  of  surgical 
endeavor.  The  frequency  of  the  occurrence  of  these  growths,  and  the  cer- 
tainty and  the  suffering  of  the  natural  outcome,  invest  the  patients  with  the 
full  measure  of  human  sympathy  and  tender  consideration.  On  the  other 
hand,  the  initial  delay  in  the  acknowledgment  of  the  presence  of  suspected 
infliction,  supplemented  by  the  procrastination  in  diagnosis  and  treatment, 
rob  the  victim  of  the  best  opportunities  of  cure,  and  thus  encourage  skep- 
tical advisers  in  the  utterance  of  their  dismal  prophecies.  Not  until  the 
presence  of  a  suspicious  growth  is  promptly  acknowledged,  and  the  diagno- 
sis and  removal  are  promptly  and  completely  made  will  the  rate  of  recovery 
from  malignant  disease  be  much  more  increased. 

When  it  is  recalled  that  about  eighty-two  per  cent  of  tumors  of  the  breast 
are  of  a  malignant  nature,  and  that  secondary  infection  has  already  occurred 
in  the  great  majority  of  cases  when  the  attention  of  the  surgeon  is  called  to 
them,  the  need  for  increased  vigilance  and  prompt  operative  action  is  apparent 
and  should  be  emphasized  by  a  carefully  conducted  explorative  incision,  if 
need  be,  to  determine  the  nature  of  the  growth. 

"  Permanent  results  will  follow  the  operative  treatment  of  carcinoma 
if  the  operation  is  performed  before  regional  infection  has  occurred  ;  on 
the  contrary,  non-recurrence  will  be  the  exception  and  recurrence  the 
rule  if  the  primary  tumor  is  not  removed  until  regional  infection  sets 
in  "  (Senn). 

The  Anatomical  Points. — The  relations  of  the  lymphatic  glands  of  the 
breast  to  those  of  the  axillary,  pectoral,  supraclavicular,  and  infraclavicular 
regions  are  of  great  importance  as  bearing  on  the  measures  of  detection  and 
removal  of  malignant  disease  and  of  its  forestallment  in  these  structures. 
The  normal  axillary  glands  are  of  comparatively  large  size,  about  ten  or 
twelve  in  number,  and  are  arranged  in  three  more  or  less  distinct  chains 
or  series.  One  chain  surrounds  the  axillary  vessels,  therefore  is  imbedded 
in  loose  areolar  tissue.  The  lymphatics  of  the  arm  are  continuous  with  this 
chain.  Another,  a  small  chain,  runs  along  the  lower  border  of  the  pectoralis 
major,  receiving  the  lymphatics  from  the  chest  and  breast.  The  third  is 
situated  at  the  posterior  border  of  the  axilla,  and  receives  the  lymphatics 
from  the  back.     The  series  communicate  with  each  other  in  the  axilla,  but 

1003 


1004 


OPERATIVE  SURGERY. 


not  so  freely  as  with  lymphatics  of  the  structures  located  closely  to  them. 
The  axillary  and  deep  cervical  lymphatics  communicate  with  each  other 
through  the  agency  of  two  or  three  lymphatic  glands  situated  beneath  the 
clavicle.  The  superficial  cervical  lymphatic  glands  immediately  above  the 
clavicle  are  connected  at  that  situation  with  the  deep  ones  beneath. 
Although,  as  before  stated,  the  major  portion  of  the  lymphatic  vessels  of 
the  mamma  empty  into  the  anterior  axillary  series,  still,  many  from  the 
iuner  margin  of  the  gland  pass  directly  through  the  intercostal  spaces  to 
communicate  with  the  mediastinal  lymphatics  (Fig.  1230).     The  lymphatic 

vessels  of  the  pectoral  muscles  and 
their  fascia  are  connected  with  those 
of  the  mamma,  and  they  pass  from 
the  gland  through  the  fatty  tissue 
beneath  to  establish  this  connection. 
The  deep  lymphatics  of  the  inferi- 
or surface  of  the  gland  accompany- 
ing the  aortic  intercostals  at  the 
outer  side  of  the  gland  going  to  the 
thoracic  duct  in  the  posterior  me- 
diastinum. The  perivascular  spaces 
of  the  small  vessels  sometimes  teem 
with  cancer  cells  carried  along  by 
the  lymph  current.  It  seems  not 
altogether  improbable  that  the  ear- 
ly blocking  of  the  axillary  lymph 
channels  by  cancer  products  hastens 
their  diffusion  through  the  minuter 
and  more  obscure  channel  to  prac- 
tically inaccessible  parts  of  the 
body.  The  intercostal  branches  of 
the  internal  mammary  artery  contribute  freely  to  the  vascular  supply  of  the 
gland,  especially  the  perforating  branches  at  the  inner  margin,  which  often 
bleed  freely  and  are  difficult  to  secure  if  severed  flush  with  the  intercostal 
structures.  The  muscular  guide  to  the  axilla  may  be  regarded  as  the  outer 
border  of  the  pectoralis  major  muscle.  The  grosser  anatomical  points  relat- 
ing to  the  mamma,  axilla,  etc.,  are  common  matters  in  any  standard  work 
on  anatomy,  and  need  not,  therefore,  encroach  unnecessarily  upon  the  oper- 
ative propriety  at  this  time. 

The  special  local  preparation  of  the  patient  relates  to  thorough  antiseptic 
cleansing  of  the  breast,  arm,  axilla,  and  the  contiguous  surfaces,  and  their 
isolation  by  antiseptic  towels.  The  axilla  especially  should  have  been 
closely  shaven  and  cleansed,  and  ulcerated  surfaces  in  the  field  of  operation  so 
purified  and  isolated  as  to  cause  no  infection. 

The  Primary  Incision. — The  varieties  of  the  primary  incisions  now  em- 
ployed in  the  removal  of  the  breast  are  considerable,  and  some,  indeed,  are 
rather  more  fanciful  than  practical.  An  incision  that  offers  ample  opportu- 
nity for  free  inspection  and  wide  removal  of  diseased  tissue  and  associated 


Fig.  1230. — A  scheme  of  important  lympliatic 
associations  of  mammary  gland,  a.  Mam- 
mary gland,  b.  Lymph  nodes  of  long 
thoracic  vessels,  c.  Lymph  nodes  between 
pectoral  mnscles.  d.  Lymph  nodes  in 
middle  of  axilla,  e.  Lymph  nodes  of  ax- 
illary vein.  /.  Lymph  nodes  in  costo-cor- 
acoid  membrane,  g.  Lymph  nodes  in  an- 
terior and  superior  mediastina.  h.  Right 
lymph  duct. 


OPKRATIONS   ON   THK   TFIORAX. 


1005 


Fig.  1231. — Instruments  employed  in  excision  of  the  mammary  gland. 

a.  Scalpels,  b.  Porcipressure.  c.  Dissecting  and  mouse-tooth  forceps,  d.  Blunt  dis- 
sector, e.  Aneurism  needle.  /.  Long  blunt-  and  sharp-pointed  scissors,  g.  Short 
blunt-pointed  scissors,  h.  Catgut  and  silkworm  gut.  i.  Long  and  curved  needles. 
j,  l\  Blunt  and  hooked  retractors.  /.  Tenaculum,  m.  Bhint  hook.  n.  Wiper. 
Forcipressure,  ligatures,  sutures,  and  wipers  in  abundance  are  needed,  and  rubber 
drainage  tubing  should  be  at  hand. 


1006 


OPERATIVE  SURGERY. 


lymphatics  may  be  regarded  as  suitable  for  operative  attainment,  irrespective 
of  previous  designation  for  the  purpose. 

Kocher's  Incision  (Fig.  1232). — The  outline  of  Kocher's  incision  is  practi- 
cally similar  to  Ilalsted's,  but  is  placed  in  a  reverse  manner  (Fig.  1238). 
The  lower  part  of  the  incision  corresponds  to  the  axillary  border  of  the  pec- 
toralis  major  and  the  upper  extremity  to  a  point  just  outside  the  middle  of 
the  clavicle.  Through  this  portion  of  the  incision  the  pectoralis  major  and 
minor  are  readily  divided,  the  axilla  freely  exposed,  and  the  vessels  and 
nerves  are  disclosed  up  to  the  clavicle.     The  inner  i)art  of  the  incision  is 

made  so  as  to  include 
the  diseased  gland  and 
the  proper  amount  of 
contiguous  tissue.  Koch- 
er's incision  is  well 
suited  for  radical  opera- 
tions. 

Senn's  (E.  J.)  Inci- 
sion. —  After  circum- 
scribing the  breast,  as 
noted  in  the  illustra- 
tion, the  incision  is  con- 
tinued at  the  outer  bor- 
der of  the  pectoral  mus- 
cle upward  to  a  point  an 
inch  above  the  border 
of  the  axilla,  thence  in 
an  outward  curved  man- 
ner terminating  at  a 
point  corresponding 
with  the  apex  of  the  axilla.  This  incision  permits  free  and  early  exposure 
of  the  vein,  and  removes  from  the  axilla  a  line  of  union  which  is  often  irri- 
tated by  perspiration,  capillary  growth,  and  imperfect  asepsis,  and  also  a  scar 
that  may  cause  subsequent  annoyance.  Ilarthy,  Keen,  Weir,  the  writer, 
and  others  have  employed  this  modification  for  three  years  or  more  with 
satisfaction. 

Warren's  Method  (Fig.  1233). —  Warren  makes  a  pear-shaped  incision, 
which,  with  removal  of  the  breast,  he  describes  as  follows : 

"  An  incision  is  made  from  the  anterior  margin  of  the  axilla  along  its 
anterior  border,  or  slightly  above,  and  the  line  of  the  pectoralis  major  muscle 
around  the  lower  border  of  the  breast  to  a  point  on  the  boundary  line  of  the 
inner  and  lower  quadrant.  A  second  incision  begins  at  the  middle  of  the 
anterior  axillary  fold  and  gradually  diverges  from  the  first  incision  as  it 
approaches  the  breast,  when  it  sweeps  around  the  upper  border  of  the  organ 
to  meet  that  incision  again  at  its  terminal  point.  The  amount  of  skin  thus 
included  is  pear-shaped,  the  point  being  at  the  upper  axillary  margin.  The 
direction  of  these  incisions  varies  somewhat  according  to  the  locality  of  the 
nodule;  but  a  very  large  amount  of  tissue  should  be  surrounded  by  them. 


Fig.  1232. — The  operation  of  excision  of  the  breast,    a, 
of  Kocher's  incision,     b.  Line  of  Senn's  incision. 


Line 


OPERATIOXS  ON   Til  hi   'I'lloUAX, 


hn)7 


usually  the  whole  breast,  luul  uceusioruilly  a  portion  of  the  juljacent  integu- 
ments. The  edges  of  the  wouud  should  be  reflected  back  and  the  dissection 
made  so  as  to  exj)ose  the  margin  of  the  mammary  gland.  The  kiiif(;  is  now 
carried  down  to  the  pectoralis  major  muscle,  which  is  freely  exposed  along 
the  line  of  the  whole  upper  incision.  Tin;  sternal  portion  of  the  pectoralis 
major  muscle  is  now  se})arated  from  the  thorax,  and  the  whole  mass  to  be 
removed  is  thrown  outward.  The  muscle  is  divided  near  its  humeral  inser- 
tion. This  exposes  freely  the  pectoralis  minor  and  the  axilla.  Should  the 
upper  incision  have  been  carried  some  distance  below  the  clavicle,  a  third 
incision  (a)  may  now  be  made  at  right  angles  to  the  first,  so  as  to  lay  bare 
the  axillary  vessels  up  to  the  })oint  where  they  pass  beneath  the  clavicle. 
The  pectoralis  minor  should  now  be  divided  and  its  halves  reflected  or 
removed.  The  dissection  of  the  axilla  follows  next,  the  axillary  vessels  being 
carefully  cleansed  of  all  adipose  tissue  from  their  point  of  emergence  beneath 
the  clavicle  down  to  and 
through  the  axilla.  Spe- 
cial attention  should  be 
paid  to  a  prolongation  of 
adipose  tissue,  which  lies 
in  front  of  the  vessels, 
and  a  similar  tongue  of 
tissue  which  runs  up  be- 
hind them.  A  thin,  blade- 
like mass  of  adipose  tissue 
lying  between  the  serra- 
tus  magnus  and  the  sub- 
scaptilaris  should  also  re- 
ceive the  attention  of  the 
surgeon,  for  here  numer- 
ous shotlike  glands  are 
found  in  the  more  malig- 
nant forms  of  the  disease. 
As  the  dissection  of  the 
axilla  proceeds  the  branch- 
es of  the  large  vessels  are 
cut  and  tied,  and  also  any  thoracic  or  scapular  nerves  which  interfere  with  a 
thorough  cleansing  of  the  part  are  cut.  The  contents  of  the  axilla  are  now 
reflected  outward,  together  with  the  mamma  and  pectoral  muscles  ;  a  few 
long  sweeps  of  the  knife  loosen  the  outer  attachments  of  the  mamma,  and 
the  whole  infected  area  is  separated  from  the  body  in  one  continuous  mass. 

"  If  there  is  any  reason  to  suspect  an  infection  of  the  supraclavicular 
glands,  the  vertical  incision  should  be  extended  above  the  clavicle ;  the  pos- 
terior cervical  triangle  can  thus  be  exposed  and  its  contents  dissected.  Divi- 
sion of  the  clavicle  does  not  add  materially  to  the  exposure  of  the  region." 

The  secondary  incisions  at  the  side  of  the  chest  (b)  are  for  the  purpose 
of  forming  flaps  with  which  to  close  the  wound  when  approximation  of  the 
borders  will  not  suffice  and  when  skin  grafting  is  not  regarded  with  favor. 


Fig.  1233. — Excision  of  the  breast.  Warren's  lines  of 
incision,  a.  Incision  to  clavicle,  b.  Incisions  for 
secondary  flaps. 


1008 


OPERATIVE   SURGERY. 


Fig.  1234. — Excision  of  the  breast.     Cheyne's  line  of  incision 
for  removal  with  central  involvement. 


Cheyne's  Incisions,  etc.  (I^^igs.  1234,  1235,  and  123G). — It  should  be  noted 
that  these  incisions  include  not  only  the  skin  covering  the  entire  breast,  but 

also  a  decided  increase 
;  of  the  area  at  the  as- 

^^^^  pect  of  the  organ  bear- 

ing the  disease.  Cheyne 
does  not  carry  the  in- 
cision straight  down 
to  the  muscle,  but  in- 
stead dissects  up  only 
sufficient  of  the  un- 
derlying fat  along 
with  the  skin  to  pre- 
serve the  vitality  of 
the  latter,  tlius  leav- 
ing behind  and  still 
connected  with  the 
tumor  the  outlying 
lobules  of  the  breast 
and  the  lymphatics 
and  vessels  contained 
in  the  deeper  fat 
which  are  connected  with  the  growth,  thereby  excluding  these  elements  of 
danger  and  rendering  easier  the  final  closure  of  the  wound.  The  pectoral 
fascia  is  invariably  removed  and  at  least  a  superficial  layer  of  the  great  pec- 
toral    muscle,     along 

with  the  diseased  gland  ^_ 

and  the  deep  fat,  pref-  ^^ 

erably    in    a    common  _«^^ 

mass.     When  diseased,  ^^^^^ 

the  pectoral  muscles 
are  entirely  removed. 
The  fasciae  connected 
with  these  muscles 
ought  always  to  be  re- 
moved. 

Cheyne  does  not 
clear  the  posterior  tri- 
angle of  the  neck  un- 
less he  detects  enlarge- 
ments there,  or  finds 
infected  nodules  in  the 
fat  lying  behind  the 
vessels  extending  into 
the  triangle. 

The  Methods  of  Operation.— The  radical   methods  of  practice  and   the 
so-called  common  method  are  recognized.     The  latter  is  superior  in  many 


Fig.  1235.— Excision  of  tiie  breast.     Cheyne's  line  of  incision 
for  removal  in  involvement  of  the  lower  border. 


OPERATIONS   OX   TIIH   'I'llORAX. 


1009 


Fig. 


respects  to  otlier  iioii-i-adicul  lueLhods  of  opunitivu  relief  of  a  comparatively 
recent  date.  The  forincr  methods  are  the  outgrowtii  of  patient  study  of  opera- 
tive results,  based  on  a  te(!hni(iue  comprehending  the  wide  removal  of  malig- 
nant manifestations,  together  witli  their  prospective  seats  of  occurrence  when 
practicable.     Warren's  and  Cheyne's  methods  are  examples  of  this  class. 

The  Position  of  the 
Patient. — Usually  the 
patient  is  placed  on  the 
back,  near  to  the  edge 
of  the  table,  the  head 
and  shoulders  raised, 
and  the  arm  extended 
from  the  side  and  re- 
tained in  position  by 
an  assistant,  an  incision 
is  made,  which  is  varied 
according  to  the  plan 
of  procedure  adopted 
by  the  surgeon. 

Halsted's  Method 
{Radical). — The  excel- 
lent results  secured  by 
Halsted  require,  it 
seems  to  us,  that  the 
technique  as  practiced 

by  him  be  presented  only  in  his  own  language.  Halsted's  method  of  prac- 
tice is  based  on  the  proposition  that  the  pectoralis  major  muscle,  entire  or  all 
except  its  clavicular  portion,  should  be  excised  in  every  case  of  cancer  of  the 
breast,  because  the  operator  is  enabled  thereby  to  remove  in  one  piece  all  of 
the  suspected  tissues. 

"  The  suspected  tissues  should  be  removed  in  one  piece  (Fig.  1237),  (1)  lest 
the  wound  become  infected  by  the  division  of  tissues  invaded  by  the  disease 
or  of  lymphatic  vessels  containing  cancer  cells,  and  (2)  because  shreds  or  pieces 
of  cancerous  tissue  might  readily  be  overlooked  in  a  piecemeal  extirpation. 

"  1.  The  skin  incision  is  carried  at  once  and  everywhere  through  the  fat 
(Fig.  1237). 

"  2.  The  triangular  flap  of  skin,  1),  «,  c,  is  reflected  back  to  its  base  line, 
c,  h.  There  is  nothing  but  skin  in  this  flap.  The  fat  which  lined  it  is  dis- 
sected back  to  the  lower  edge  of  the  pectoralis  major  muscle,  where  it  is  con- 
tinuous with  the  fat  of  the  axilla. 

"  3.  The  costal  insertions  of  the  pectoralis  major  muscle  are  severed,  and 
the  splitting  of  the  muscle,  usually  between  its  clavicular  and  costal  por- 
tions, is  begun  and  continued  to  a  point  about  opposite  the  scalenus  tubercle 
on  the  first  rib. 

"  4.  At  this  point  the  clavicular  portion  of  the  pectoralis  major  muscle 
and  the  skin  overlying  it  are  cut  through  hard  up  to  the  clavicle.  This  cut 
exposes  the  apex  of  the  axilla. 


1236. — Excision  of  the  breast.     Cheyne's  line  of  incision 
for  removal  in  involvement  of  the  upper  border. 


1010 


OPERATIVE   SURGERY. 


"  5.  Tlie  loose  tissue  under  tlie  clavicular  portion  (the  portion  usually 
left  behind)  of  the  pectoralis  major  is  carefully  dissected  from  this  muscle 
as  the  latter  is  drawn  upward  by  a  broad,  sharp  retractor.  This  tissue  is 
rich  in  lymphatics,  and  is  sometimes  infiltrated  with  cancer  (an  important 
fact). 

"0.  The  splitting  of  the  muscle  is  continued  out  to  the  humerus,  and 

the  part  of  the  muscle 
to  be  removed  is  now 
cut  through  close  to  its 
humeral  attachment. 

"  7.  The  whole  mass 
— skin,  breast,  areolar 
tissue,  and  fat — circum- 
scribed by  the  original 
skin  incision  is  raised 
up  with  some  force,  to 
put  the  submuscular 
fascia  on  the  stretch  as 
it  is  stripped  from  the 
thorax  close  to  the  ribs 
and  pectoralis  minor 
muscle.  It  is  well  to 
include  the  delicate 
sheath  of  the  minor 
muscle  when  this  is 
practicable  (Fig.  1339). 
"  8.  The  lower  outer 
border  of  the  minor 
muscle  having  been 
passed  and  clearly  ex- 
posed, this  muscle  is  di- 
vided at  right  angles  to 
its  fibers  and  at  a  point 
a  little  below  its  middle. 
"9.  The  tissue,  more 
or  less  rich  in  lymphat- 
ics and  often  cancerous, 
over  the  minor  muscle, 
near  its  coracoid  inser- 
tion, is  divided  as  far  out  as  possible,  and  then  reflected  inward  in  order  to 
liberate  or  prepare  for  the  reflection  upward  of  this  part  of  the  minor  muscle. 
"  10.  The  upper  outer  portion  of  the  minor  muscle  is  drawn  upward 
with  a  broad,  sharp  retractor  (a).  This  liberates  the  retractor,  which  until 
now  has  been  holding  back  the  clavicular  portion  of  the  pectoralis  major 
muscle. 

"  11.  The  small  blood-vessels  (chiefly  veins)  under  the  minor  muscle,  near 
its  insertion,  must  be  separated  from  the  muscle  with  the  greatest  care. 


Fig.  1237. — Excision  of  the  breast,  Halsted's  method. 
Tissues  removed  en  masse. 


OPKRATIONS   (t.\    TIIK   TIloifAX. 


1011 


These  jirc  imbedded  in  loose  eonnective  tissue  vvliich  seems  to  be  rich  in 
lymplmtics,  and  contains  more  or  less  fat.  This  fat  is  often  infiltrated  with 
cancer.  These  blood-vessels  should  be  dissected  out  very  clean  and  imme- 
diately ligatod  close  to  the  axillary  vein.     The  ligation  of  these  very  delicate 


V: 


Fig.  1238.— Excision  of  the  breast,  Halsted's  method. 

Base  line. 


b,  a,  c.   Triangular  flap,      b,  c. 


vessels  should  not  be  postponed,  for  the  clamps  occluding  them  might  of 
their  own  weight  drop  oif  or  accidentally  be  pulled  off,  or  the  vessels  them- 
selves might  be  torn  away  by  the  clamps.  Furthermore,  the  clamps — so  many 
of  them — if  left  on  the  veins  would  be  in  the  way  of  the  operator. 

"  12.  Having  exposed  the  subclavian  vein  at  the  highest  possible  sub- 
clavicular point,  the  contents  of  the  axilla  are  dissected  away  with  scrupu- 
lous care,  also  with  the  sharpest  possible  knife.  The  glands  and  fat  should 
not  be  pulled  out  with  the  fingers,  as  advised,  I  am  sorry  to  say,  in  modern 
text- books  and  as  practiced  very  often  by  operators.  The  axillary  vein 
should  be  stripped  absolutely  clean.  Not  a  particle  of  extraneous  tissue 
should  be  included  in  the  ligatures  which  are  applied  to  the  branches, 
sometimes  very  minute,  of  the  axillary  vessels.  In  liberating  the  vein  from 
the  tissues  to  be  removed,  it  is  best  to  push  the  vein  away  from  the  tissues, 
rather  than  hold  the  vein  and  push  the  tissues  away  from  it.  It  may  not 
70 


1012 


OPERATIVE   SURGERY. 


always  be  necessary  to  expose  the  artery,  but  I  think  that  it  is  well  to  do 
this,  for  sometimes,  not  usually,  the  tissue  above  the  large  vessels  is  infil- 
trated, and  we  should  not  trust  our  eyes  and  fingers  to  decide  this  point. 
It  is  best  to  err  on  the  safe  side,  and  to  remove  in  all  cases  the  loose  tissue 
above  the  vessels  and  about  the  axillary  plexus  of  nerves. 

"  13.  Having  cleaned  the  vessels,  we  may  proceed  more  rapidly  to  strip 
the  axillary  contents  from  the  inner  wall  of  the  axilla — the  lateral  wall  of 
the  thorax.  We  must  grasp  the  mass  to  be  removed  firmly  with  the  left 
hand,  and  pull  it  outward  and  slightly  upward  with  sufficient  force  to  put 
on  the  stretch  the  delicate  fascia  which  still  binds  it  to  the  chest.  This 
fascia  is  cut  away  close  to  the  ribs  and  serratus  magnus  muscle. 


Fig.  1389.— Excision  of  the  breast,  llalsted's  inelhod.  a.  Reflected  part  of  peetoralis 
minor  muscle,  a'.  Central  part  of  peetoralis  minor  muscle,  h.  Humeral  insertion 
of  sternal  portion  of  peetoralis  major,  b' .  Severed  part  of  sternal  poi-tion  of  pee- 
toralis major,     c,  r'.  Fatty  prolongations  bearing  lymph  nodes. 

"  14.  When  we  have  reached  the  junction  of  the  posterior  and  lateral 
walls  of  the  axilla,  or  a  little  sooner,  an  assistant  takes  hold  of  the  triangular 
flap  of  skin  and  draws  it  outward,  to  assist  in  spreading  out  the  tissues 
which  lie  on  the  subscapularis,  teres  major,  and  latissimus  dorsi  muscles. 
The  operator  having  taken  a  different  hold  of  the  tumor,  cleans  from  within 
outward  the  posterior  wall  of  the  axilla.  Proceeding  in  this  way,  we  make 
easy  and  bloodless  a  part  of  the  operation  which  used  to  be  troublesome  and 
bloody.  The  subscapular  vessels  become  nicely  exposed  and  caught  before 
they  are  divided.  The  subscapular  nerves  may  or  may  not  be  removed,  at 
the  discretion  of  the  operator.     Kiister  lays  great  stress  upon  the  importance 


()Im:i;ati()Ns  on  tuI';  tiiouax. 


](ii;} 


of  tlu'so  nerves  for  tlie  siibscciueiit  usefulness  of  the  ariii.  A\'e  liuve  not  us 
yet  decided  this  point  to  our  entire  sutisfaetion,  but  I  think  that  they  may 
often  be  spared  to  the  patient  with  safety. 

"  15.  llavinrj  passed  these  nerves,  the  operator  lias  only  to  turn  the  mass 
back  in  its  normal  position,  and  to  sever  its  connection  with  the  body  of  the 
patient  by  a  stroke;  of  tlic  knife  from  //  to  c^  repeating  the  first  cut  through 
the  skin. 

"The  edges  of  the  wound  ai'e  approximated  \)\  a  Ijuried  j)urse-string 
suture  of  strong  silk.  Of  the  triangular  llap  of  skin  [h,  a,  c)  only  the  base  is 
included  in  this  suture.  The  rest  of  this  llap  is  used  as  a  lining  for  the 
fornix  of  the  axilla.  The  apex  (a)  of  this  tlap  is  conserpiently  shifted  to  a 
new  and  lower  position.  The  axilla  is  never  drained,  and  invariably  heals 
by  first  intention.  The  uncovered  wound  often  heals  by  the  so-called  organi- 
zation of  the  blood  clot." 

Meyer's  Method  ( l\(tdi<-al). — Meyer's  plan  of  action,  with  which  Ilalsted's 
is  sometimes  historic-ally  associated,  while  seeking  the  same  ends  as  the  latter, 
differs  somewhat  in  the  details,  and,  like  it,  is  substantially  quoted  in  full 
for  the  benefit  of  the  operator. 

Tlie  Operation. — "  Make  the  primary  incision  as  usual,  embracing  a  liberal 
piece  of  skin  around  the  nipple  (Fig.  124:0,  a,  d),  which  incision  is  at  once 
run  up  into  the  axillary  cavity, 

about  an  inch  and  a  half  to  two       ;/,),„, if/ikA 

mclies  farther  than 
in      the      ordinary 
operation  {d).  This 
is    done    in    order 
more  easily  to  reach 
the  tendon   of    the 
pectoralis        major 
muscle  on  the  hu- 
merus ;  make  an  ad- 
ditional   skin   inci- 
sion from  the  clavicle  at  the  junc- 
tion   of    its    middle    and    outer 
thirds    downward,    meeting   the 
first  wound  at  right  angles  (c,  d) ; 
reflect  the  skin  flaps,  with  as  thin 
a  layer  of  the  underlying  fat  as 
possible,  leaving  just  enough  so 
as  not  to  endanger  a  future  ne- 
crosis of  the  flaps,  exposing  (Fig. 
1241) :    1.  The   insertion  of  the 
pectoralis  major  (p)   muscle  to 
the  clavicle  and  sternum.    2.  The 

insertion  of  the  same  muscle  to  the  humerus  (f),  the  cephalic  vein  (c,  v)  in 
Mohrenheim's  subclavicular  space.  3.  The  border  of  the  latissiraus  dorsi 
muscle  {I,  d) ;   divide  the  pectoralis  major   muscle  in   its   tendon  close  to 


Fig.  1240. — Excision  of  the  breast,  Meyer's  meth- 
od, a.  d.  Primary  incision  around  breast. 
b.  Upper  limit  of  incision,  c,  d.  Vertical  in- 
cision from  jiMiction  of  middle  and  center 
thirds  of  clavicle. 


1014 


OPERATIVE  SURGERY. 


the  humerus  (the  raised  arm  of  the  patient  must  be  somewhat  lowered  for 
this  purpose),  and  separate  the  same  to  its  insertion  into  the  clavicle.  Cut 
it  off  at  once  down  to  the  sternal  extremity  of  the  bone,  in  order  to  thor- 
oughly expose  the  contents  of  the  axillary  cavity  and  the  infraclavicular 
and  subclavicular  region.  During  this  time  an  assistant  exerts  some  traction 
on  the  breast  to  put  the  tissues  on  the  stretch ;  excise  the  subclavicular, 

infraclavicular,  and  ax- 
"t'|(  ^  illary  fat,  glands,  and 

lymphatics,  with  the 
knife,  beginning  over 
the  bundle  of  nerves 
and  vessels  high  up  in 
the  cavity,  and  contin- 
uing downward  from 
the  lower  border  of  the 
subclavian  and  axillary 
vein.  As  soon  as  freed, 
these  contents,  having 
been  divided  on  the 
outer  side  from  the  fat 
in  the  upper  part  of 
the  sulcus  bicipitalis 
of  the  arm,  are  raised 
and  cut  out  from  the 

Fig.  1241.— Excision  of  the  breast,  Meyer's  method,  p.  Pec-  ^^}^^^[  ^^^®  inward,  be- 
toralis  major  muscle,  t.  Tendon  of  pectoralis  major  mus-  ginning  at  the  border 
cle  c.v.  Cephalic  vein  in  3Iohrenheim-s  space.  U.  f  ^^le  latissimus  dorsi 
Latissimus  dorsi  muscle. 

muscle.     This  excision 

is  continued,  including  the  fat  on  the  subscapularis  and  teres  major  mus- 
cles, until  the  chest  walls — viz.,  ribs,  intercostal,  and  part  of  the  serratus 
magnus  muscles — are  plainly  seen,  and  until  the  '  lower '  surface  of  the 
pectoral  muscles  is  reached.  Fat  with  glands  and  lymphatics  are  nowhere 
cut  into,  but  remain  in  one  piece,  and  are  attached  to  the  outer  lower  border 
of  the  pectoral  muscles  in  their  normal  anatomical  relation.  Divide  the 
tendon  of  the  pectoralis  minor  muscle  at  the  coracoid  process ;  cause  the 
assistant  to  gently  elevate  the  breast  and  muscles,  in  order  to  put  the  blood- 
vessels, which  enter  and  leave  the  pectoralis  major  muscle,  on  the  stretch. 
As  mentioned  above,  these  are  clamped  before  they  are  divided.  Amputate 
the  pectoralis  major  muscle  at  its  attachment  to  the  sternal  extremity  of 
the  clavicle,  and  both  muscles  at  their  insertions  to  the  ribs  and  sternum 
close  to  the  bones.  These  portions  form  the  pedicle  of  the  whole  mass, 
and  when  divided  the  extirpation  of  the  cancer  is  complete.  Suture  the 
wound  as  far  as  possible,  using  plate  sutures  for  the  sake  of  better  coapta- 
tion ;  drain  the  axillary  cavity  as  usual.  The  large  defect  is  always  to  be 
covered  with  rubber  tissue  in  order  to  favor  rapid  healing  under  the  moist 
blood  clot." 

The  Precautio7is. — In  order  that   no  chance  of  cancer  infection  of  a 


OPKUATIONS   ON    Till-;   "lilolfAX.  1015 

wound  can  happen  during  operation,  infec^ted  glands  and  lynipiiatics  sliould 
be  removed  witliout  division  when  possible.  And,  if  divided,  they  should 
be  wrapped  in  gauze  at  once,  and  the  wouiul  freely  douclied  to  wash  away 
the  i)ossible  contamination.  Healthy  tissue  should  not  be  incised  with  a 
knife  contaminated  by  contact  with  malignant  tissue  until  after  a  thorough 
cleansing  of  the  instrument.  Free  liandling  of  a  cancerous  growth  sliould 
not  be  succeeded  by  manual  contact  of  fresh  wound  surfaces  with  unwaslied 
hands.  The  removal  of  malignant  extension  should  be  done  from  outside 
of  the  diseased  area,  and  not  from  within  it,  from  motives  of  safety.  Tear- 
ing and  blunt  dissection  of  the  infected  tissues  should  be  avoided,  and  keen 
division  with  a  sharp  knife  practiced  for  apparent  reasons.  The  mainte- 
nance of  the  integrity  of  the  clavicular  portion  of  the  pectoral  muscle  is 
usually  feasible  in  thorough  operative  procedure,  and  is  essential  to  the  prac- 
tical use  of  the  arm  in  the  absence  of  the  sternal  part  of  the  muscles.  A 
protracted  fixation  of  the  limb  in  one  position,  or  the  construction  of  a 
shallow  axilla,  contribute  greatly  to  impeded  movements  of  the  extremity. 
Enlarged  glands  located  within  the  area  influenced  by  the  growth  should  be 
sought  for  and  removed  along  with  contiguous  connective  tissues.  The 
supraclavicular  and  infraclavicular  spaces  should  not  escape  attention,  and 
may  be  wisely  divested  of  their  lymphatic  structures  in  many  cases,  irre- 
spective of  the  presence  of  evidences  of  infection. 

The  Remarks. — Mammary  cancers  of  the  smallest  size  may  have  caused 
already  lymphatic  and  muscular  infection.  Axillary  lymphatic  glands  may 
have  become  infected  without  the  occurrence  of  appreciable  enlargement 
therefrom.  In  malignant  involvement  of  the  fascia  covering  the  pectoral 
muscle  the  muscle  itself  may  be  free  from  the  disease,  as  the  lymphatic  sys- 
tems of  these  structures  do  not  communicate  freely  in  the  majority  of 
instances.  However,  the  efl'ect  of  non-muscular  involvement  should  not  be 
assumed ;  it  should  be  a  matter  of  established  surety. 

"A  tumor,  however  freely  movable  on  the  underlying  parts,  has  almost 
certainly  advanced  as  far  as  the  surface  of  the  muscle "  (Heidenhain). 
"  The  efficiency  of  an  operation  is  measured  truer  in  terms  of  local  recur- 
rence than  of  ultimate  cure  "  (Halsted).  Any  deficiency  in  the  integumen- 
tary flap  that  may  follow  a  special  plan  of  treatment,  or  of  a  wide  removal  of 
the  disease,  can  be  repaired  at  once,  or  later  by  Thiersch's  method  of  skin 
grafting. 

The  recognized  inability  to  remove  entirely  the  disease  contraiudicates 
any  method  of  attempt,  unless  it  be  done  to  improve  the  morale  of  the 
patient  or  to  secure  euthanasia.  If  a  breast  be  affected  with  malignant  dis- 
ease, the  entire  organ  should  be  removed  at  once. 

It  is  important  to  note  that  the  margin  of  the  normal  breast  extends 
much  beyond  the  limits  determined  by  palpation — a  fact  especially  notice- 
able in  the  removal  of  virgin  breasts  and  those  freely  clad  with  adipose 
tissue.  The  tissues  contiguous  to  the  axillary  vein  and  those  at  the  inner 
aspect  of  the  apex  of  the  axilla  are  the  most  frequent  seats  of  malignant 
infection,  and  next  in  order  is  the  fatty  tissue  behind  the  vessels,  thence 
upward  to  the  posterior  portion  of  the  subclavian  triangle.     The  condition 


1016 


OPERATIVE   SURGERY. 


of  the  glands  lying  between  the  pectoral  muscles  and  those  associated  with 
the  vein  as  it  lies  contiguous  to  the  first  rib,  especially  the  latter,  are  a 
fair  index  of  the  condition  of  those  beyond.  In  1880  Gross  expressed  the 
opinion  that  supraclavicular  lymph  nodes  were  infected  in  G.25  per  cent 
of  the  instances  of  axillary  node  involvement.  Hahted  has  demonstrated  by 
microscopical  examination  of  the  tissues  removed  from  this  space  that  infec- 
tion is  present  in  the  lymph  nodes  in  34  per  cent  of  the  instances. 

The  operative  technique  of  the  less  radical  methods  of  procedure  is  fairly 
represented  in  the  following  statement: 

The  Operation. — Make  an  elliptical  incision  through  the  skin  and  fascia 
from  a  point  opposite  the  center  of  the  axilla  (Fig.  1242)  downward  par- 
allel with  the  anterior  fold,  ending  just  beyond  the  mamma,  of  sufficient 
width  to  provide  an  ample  amount  of  sound  integument  at  either  side  of 
the  morbid  growth  ;  divide  the  tissues  beneath  the  upper  incision  down  to 

the  pectoral  muscle,  while  the 
assistant  draws  upward  the  in- 
tegument and  the  operator 
presses  downward  the  breast, 
so  that  it  is  forced  well  out  of 
the  way  ;  turn  the  breast  down- 
ward and  expose  the  pectoral 
muscle  by  blunt  and  sharp  dis- 
section, closing  the  bleeding 
points  by  forcipressure ;  place 
between  the  separated  struc- 
tures an  aseptic  towel ;  divide 
the  tissues  beneath  the  lower 
incision  as  carefully  as  were 
those  of  the  upper,  while  con- 
verse force  is  being  exercised ; 
raise  the  growth  and  sever  the 
remaining  inferior  connections, 
catching  the  bleeding  points 
as  they  appear ;  dissect  away  the  overlying  pectoral  fascia  and  such  portions 
of  the  muscle  as  are  diseased  ;  introduce  the  finger  through  the  upper  end 
of  the  incision  into  the  axilla,  and  search  for  enlarged  glands,  especially 
along  the  course  of  the  anterior  axillary  chain  of  lymjihatics ;  expose  at  the 
upper  end  of  the  incision  the  axillary  vein ;  raise  upward  the  pectoral  mus- 
cle, and  remove  by  blunt  dissection  inward  and  downw^ard  with  the  finger 
the  diseased  glands  and  contiguous  connective  tissue,  removing  if  practicable 
the  entire  mass  at  once  (Fig.  1243) ;  tie  the  bleeding  points  with  catgut ; 
establish  drainage  openings  at  the  dependent  parts ;  irrigate  the  wound 
with  an  antiseptic  solution  ;  dry  it  carefully  with  gauze  pressure ;  introduce 
the  sutures  first  at  the  upper  and  lower  ends  of  the  wound  (Fig.  1244) ;  later 
introduce  the  drainage  tube  and  the  sutures  of  the  middle  part  of  the  wound 
by  means  of  a  short  free  incision  or  puncture;  adjust  the  borders  of  the 
wound  carefully,  and  tie  the  sutures  throughout,  following  up  the  line  of 


Pig.  1242. — Excision  of  the  breast,  so-called  conserv 
ative  method,  a.  Lines  of  [)rimary  incision 
b.  Drainage  opening. 


()|'i:i{A'ri()XS   ox    'IMIK    I'lIolfAX. 


1<»1 


Fig.  1243. — Excision   of  tlie  breast,  so-called   conserva- 
tive  method.     Removal  of  diseased  mass. 


tving  with  eoiitiimou.s  sj)uii«i;e  prcssiii'c  ;  I'cmovi'  tliu  .spongL-s  in  the  order  ol 
application,  and  dust  the  line  of  union  witli  iodoform,  covering  it  with 
broad    strip   of    iodo- 


a 

form  gauze ;   reapply  for 
pressure    purposes    along 
the    line   of    the    wound 
fresh   sponges,  or  elastic 
gauze   dress- 
ing instead ; 
carry        the 
arm      across 
the  chest  at 
about  aright 

angle,  keeping  the  elbow 
at  the  side,  or  place  the 
hand  on  the  opposite 
shoulder,  carefully  intro- 
ducing beneath  the  limb 
for  the  entire  length  suffi- 
cient dressing  to  obliter- 
ate completely  the  wound, 
and  comfortably  pad  the 
parts  without  constriction 
of   the   circulation ;    raise 

the  patient  into  the  sitting  posture,  if  practicable,  and  bandage  the  arm  to 
the   body,  carefully  noting  the  influence  of     the  bandaging  on  the  radial 

pulsations ;  secure  the  bandage 
in  place  with  numerous  safety 
pins,  return  the  patient  to  bed, 
and  leave  in  as  comfortable  a 
position  as  practicable. 

The  continement  of  the  arm 
at  a  right  angle  with  the  chest 
after  operation  for  cancer  of  the 
breast,  to  avoid  the  immobility 
that  often  follows  confinement 
at  the  side,  is  approved  by 
Cheyne.  Dowd  has  devised  a 
jacket  to  support  the  dressings, 
without  confinement  of  the  ex- 
tremity, which  he  regards  with 
great  favor. 

The  Precautious. — The  re- 
moval of  apparently  diseased 
tissue  from  within  the  area  of  surgical. scope  in  the  conservative  method  of 
practice  should  be  thoroughly  done,  and  prospective  sites  of  malignancy  re- 
moved in  the  more  radical  methods  of  action. 


Fig.  1244. — Excision  of  the  breast,  so-called  con 
servative  method.  Drainage  openings  indi 
cated. 


1018  OPERATIVE  SURGERY. 

The  General  Remarlcs.—T\\G  security  of  tlic  axillary  vein  and  the  prompt- 
ness of  surgical  dispatch  in  the  removal  of  diseased  structures  from  the  axilla 
are  sometimes  greatly  facilitated  by  primary  exposure  of  the  vein  at  the 
outer  limit,  followed  by  dissection  and  separation  inward  along  the  vessels  to 
the  center  of  the  axilla. 

The  lower  incision  may  be  made  first,  thus  avoiding  the  annoyance  and 
obscuration  caused  by  the  flow  of  blood  from  a  primary  upper  incision.  If 
the  axillary  vein  be  involved,  the  diseased  portion  should  be  removed  between 
two  ligatures.  The  subscapular  vein  often  requires  tying — a  fact  of  no  spe- 
cial significance.  Proper  observation  a-.d  complete  and  safe  removal  of  the 
diseased  nodes  at  the  apex  of  the  axilla  require  division  of  the  pectoral  mus- 
cles, which  may  be  thereafter  removed  or  repaired  by  sewing,  as  circum- 
stances demand. 

A  free  incision  made  in  the  long  axis  of  the  clavicle,  or  the  turning 
upward  of  a  flap  limited  by  the  posterior  border  of  the  sterno-mastoid  muscle 
of  sufficient  size  to  expose  the  glands  in  the  supraclavicular  space,  can  be 
employed.  The  latter  is  better  calculated  to  meet  the  full  requirements  of 
the  procedure. 

When  practicable,  the  skin  incision  for  removal  of  the  breast  may  be 
so  planned  as  to  secure  proper  apposition  of  the  margins  of  the  wound.  The 
influence  of  traction  sutures,  inserted  far  away  from  the  margin  of  the 
wound  and  tied,  is  of  decided  importance  in  securing  coaptation  of  the  bor- 
ders in  instances  of  scant  integumentary  flaps. 

Treves  advises  that  the  arm  be  abducted  and  the  hand  placed  behind  the 
head,  and  held  there  by  the  anaesthetist  during  the  operation.  The  axilla 
should  be  shaven  closely,  so  as  to  avoid  as  much  as  possible  the  irritation 
incident  to  growing  hairs  during  recovery.  All  bleeding  points  should  be 
tied  with  flne  strong  catgut,  to  avoid  the  oozing  that  may  follow  a  less  secure 
means  of  closure.  The  wound  should  be  cleansed  by  douching,  and  dried 
by  compression  with  gauze  or  sponges,  and  not  wiped  by  either.  Careful 
obliteration  of  the  entire  wound  by  gauze  or  sponge  pressure  should  be 
secured,  to  avoid  the  presence  of  dead  spaces.  A  return  of  the  disease  in 
the  line  of  operative  procedure  can  not  be  disregarded,  as  it  strongly  em- 
phasizes the  facts  of  incomplete  removal  and  defective  technique. 

Amjmtation  at  the  extremity  for  removal  of  cancerous  disease  of  the 
axilla  can  not  be  commended  as  a  means  of  cure.  In  cases  amenable  to  this 
plan  the  disease  has  no  doubt  extended  so  far  beyond  the  axilla  as  to  forbid  the 
amputation  with  the  expectation  of  final  relief.  However,  in  instances  where 
excessive  pain  from  brachial  plexus  involvement  torments  the  patient,  the 
expediency  of  amputation  may  then  be  entertained  for  the  purposes  of 
euthanasia. 

The  after-treatment  consists  largely  in  attending  to  the  comfort  of  the 
patient.  The  wound  should  be  redressed  on  the  third  day  and  the  drainage 
agent  removed  if  employed,  unless  soiling  of  the  dressings  or  unexpected  hap- 
penings call  for  prompter  action.  Thereafter  the  dressing  is  not  changed 
for  five  or  six  days,  and  perhaps  longer  in  many  cases.  The  sutures  are 
removed  in  a  week  or  ten  days,  and  the  arm  is  liberated  at  about  the  same 


Ol'KRATlUNS   ON    TllK   TllOKAX.  1019 

time.  The  patient  is  ordered  out  of  bed  during  the  second  week  usually, 
and  should  be  around  a  few  days  later.  Early  movement  of  the  limb  is 
advisable,  to  remedy  as  promjjtly  as  ])ossible  any  restricted  motion  that  may 
ensue.  A  careful  scrutiny  of  the  patient  should  be  practiced  at  intervals  of 
six  or  eight  weeks  for  a  long  time,  to  detect  the  earliest  manifestations  of  a 
recurrence.  Prompt,  wide,  and  repeated  removal  should  follow  successive 
manifestations,  when  practicable. 

The  Results. — The  death  rate  (about  2  per  cent)  from  the  operation 
alone,  when  performed  with  aseptic  care,  according  to  any  established  meth- 
od, does  not  contraindicate  the  measure  in  operable  cases.  Inasmuch  as 
the  deltoid  and  coraco-brachialis  muscles  assist  the  pectoral  muscle  in 
drawing  the  arm  forward  and  inward,  the  removal  of  the  greater  portion  of 
the  latter,  while  not  lessening  materially  the  range  of  movements  of  the 
arm,  does  diminish  decidedly  the  power  of  these  movements.  Other  things 
being  equal,  the  frequency  of  the  recurrence  and  the  brevity  of  the  period 
of  local  return  are  the  proper  measures  of  the  value  of  an  operation  for  the 
eradication  of  malignant  disease.  In  1889  Williams,  from  the  experience  of 
the  Middlesex  Hospital,  stated,  according  to  Treves,  that  "  the  average  dura- 
tion of  life,  dating  from  the  time  the  disease  was  first  noticed,  is  60.8  months 
for  those  who  undergo  operation,  and  44.8  months  for  those  in  whom  the 
disease  runs  its  natural  course.  The  average  duration  of  life  subsequent  to 
amputation  of  the  breast  is  40.3  months.  The  average  interval  between  the 
first  operation  and  the  first  recurrence  is  26  months ;  the  maximum,  130 
months;  the  minimum,  2.5  months."  Warren's  experience  places  the  mor- 
tality rate  at  2  per  cent,  and  40  per  cent  as  alive  and  well  at  the  end  of 
three  years.  Cheyne  reports  that  in  99  unselected  cases  56  were  free  from 
disease  from  one  to  nine  years,  also  that  in  61  of  the  99,  30  were  free  from 
recurrence  at  the  end  of  three  years. 

In  1894  Halsted  published  the  outcome  of  fifty  cases  operated  on  by  him- 
self since  June,  1889,  and  estimated  along  the  same  lines  of  consideration  as 
those  of  similar  reports  published  elsewhere,  especially  by  eminent  German 
surgeons.  The  results  attracted  marked  attention  on  account  of  the  com- 
paratively high  degree  of  success  which  they  exhibited,  and  the  direct  rela- 
tion that  it  seemed  to  bear  to  the  logic  of  extensive  and  thorough  operative 
technique.  However,  since  many  of  the  cases  had  not  then  reached  the  three- 
year  limit  of  cure,  an  announcement  of  the  final  result  was  awaited  with  deep 
interest  by  thoughtful  surgeons.  Halsted  has  recently  announced  that  over 
52  per  cent  of  his  patients  have  lived  more  than  three  years  after  operation 
without  local  return  or  metastasis. 

The  general  average  of  trustworthy  reports  based  on  the  three-year  limit 
show  a  rate  of  cure  of  about  40  per  cent. 

Only  the  results  of  the  general  average  of  stated  methods  of  operation 
are  considered,  because  the  announcement  of  improved  results  in  a  limited 
number  of  cases  without  definite  expression  as  to  the  technique  employed 
should  be  regarded  as  being  of  a  greater  personal  interest  than  of  scien- 
tific importance. 

The  Choice  of  Operation.— We  employ  the  radical  method  whenever  prac- 


1020 


OPKRATIVE   SURGERY. 


/'/   /I 


/' 


1^ 


P'lG.    1245. — Excision  of  tlie   mam 
mary  gland.     Tliomas's  method. 


ticable,  and,  in  onr  opinion,  little  remains  to  be  said  regarding  this  matter 
from  the  standpoint  of  surgical  expediency.  The  average  standard  of 
attainment  of  the  older  and  less  radical  methods  appears  to  have  reached 

already  its  highest  altitude.     The  advent  of 
,  the  newer,  a  radical  and  more  logical  plan 

of  action,  with  a  much  greater  percentage  of 
achievement,  and  without  proportional  dan- 
ger, begets  renewed  hope,  which  should  be 
sustained  by  like  surgical  endeavor  until  the 
true  value  of  the  measure  is  established.  A 
radical  operation  is  indicated  in  all  cases  in 
which  general  infection  has  not  occurred, 
and  local  manifestations,  together  with  the 
prospective  sites  of  malignant  advance,  ad- 
mit of  complete  removal  without  immediate- 
ly exposing  to  unusual  danger  the  life  of  the 
patient. 

Non-malignant  Tumors.— In  the  removal 
of  non-malignant  tumors  from  the  breast 
the  incisions  should  be  so  formed  as  to  cause 
the  least  possible  final  disfigurement  or  in- 
terference with  the  function  of  the  organ. 
The  nipple  is  the  most  essential  feature,  and  should  be  preserved  when 
possible. 

The  pectoral  border  of  the  axillary  fold  can  be  pulled  toward  the  median 
line  of  the  body,  and  the  breast  removed  through  an  incision  corresponding 
with  the  direction  of  the  fold,  and  the        , 
return  of  the  tissues  to  the  natural  site 
will  hide  the  cicatrix  and  present  an 
undisfigured  surface  to  view. 

Thomas's  Method. — Thomas  carried 
around  the  lower  margin  of  the  breast 
in  the  line  of  the  mammary  fold  an  in- 
cision of  sufficient  length  and  depth  to 
permit  the  easy  turning  upward  of  the 
organ  (Fig.  1245).  The  diseased  por- 
tion of  the  gland  was  then  removed 
from  beneath  without  involvement  of 
the  integument  above,  the  breast  re- 
turned to  the  normal  position,  and  the 
divided  borders  were  united  with  su- 
tures. In  these  instances  the  nipple 
can  usually  be  saved,  and  recovery  takes 
place  with  a  minimum  degree  of  scarring 
in  several  instances  with  entire  success. 

Thoracentesis. — The  tapping  of  the  pleural  cavity  for  the  relief  of  pleural 
effusions  especially  and  of  hydrothorax  is  a  common  procedure  (Figs.  1091 


Fig.  1246. — Tlinracentesis.  Pitch's  aspira- 
tor, a.  Trocar,  g.  Cannula,  c,  c. 
Couplings,  e.  Rubber  tube.  /,  /. 
Glass  tube  sections. 

We  have  practiced  this  method 


OlM'MiA'I'IoXS   ON    TIIK   'I'lloKAX.  1021 

and  KUK)).  The  aspii'iitor  with  the  troc;ir  and  eunnula  attachment  is  better 
than  the  needle  alone,  as  tlie  latter  may  inflict  injury  on  the  lung  tissue, 
esj)ecially  during  the  witiidrawal  of  the  lluid  (Fig.  1:^4(1). 

The  A)iatomic(tl  Points. — 'i'iie  intercostal  vessels  and  nerves  run  along 
the  contiguous  borders  of  the  ribs,  sheltered  somewhat,  especially  at  the 
posterior  halves,  by  the  grooved  arrangement  of  their  lower  borders.  The 
attachments  to  the  walls  of  the  thorax,  of  the  diaphragm,  and  the  iniluence 
on  its  relations  to  the  thoracic  contents  of  the  respiratory  acts,  are  often 
imjiortant  in  this  oi)eration,  and  therefore  the  consulting  of  a  standard  work 
on  anatomy  in  this  regard  may  not  be  amiss.  The  intercostal  spaces,  espe- 
cially at  the  accepted  points  of  puncture,  are  easily  and  safely  penetrated. 

Tlie  Operation. — The  sixth  intercostal  space  in  the  midaxillary  and  the 
eighth  in  the  scapular  lines  are  the  sites  usually  selected  for  the  puncture. 
Place  the  patient  on  the  back  with  the  atHicted  side  at  the  edge  of  the  bed  ;. 
raise  the  arm  out  of  the  way ;  cleanse  the  part  thoroughly  and  draw  the  skin 
upward  at  the  seat  of  attack  and  hold  it  with  the  thumb  and  fingers;  cocain- 
ize the  part  and  then  puncture  the  skin  near  to  the  upper  edge  of  the 
lower  rib  of  the  chosen  space  with  a  narrow  knife ;  thrust  into  the  punc- 
ture the  trocar  or  needle  inward  and  ui:)ward  through  the  pleura  limiting 
the  extent  of  penetration  by  the  finger ;  draw  off  the  fluid  slowly,  regulating 
the  flow  by  the  symptoms  of  the  patient.  If  blood  appear,  withdraw  the 
needle  at  once.     The  wound  is  closed  and  sealed  with  collodion. 

The  Precautions. — Before  tapping  is  performed,  the  nature  of  the  fluid 
and  the  proper  seat  of  the  puncture  should  be  determined  by  the  agency  of 
a  hypodermic  syringe.  In  tapping  be  sure  to  enter  the  chest  cavity  and  to 
avoid  at  the  same  time  the  lung.  With  a  limited  collection  of  fluid  the 
latter  may  be  easily  injured,  unless  wise  forethought  be  exercised.  The  fluid 
should  be  withdrawn  slowly,  as  rapid  escape  may  cause  syncope,  oedema  of 
the  lung,  and  other  disagreeable  and  perhaps  dangerous  manifestations.  The 
withdrawal  should  cease  in  such  instances  and  not  be  resumed  until  after 
suitable  restoration  is  established.  The  integument  should  be  drawn  upward 
at  the  seat  of  proposed  puncture  to  a  degree  proportionate  to  the  distention 
of  the  chest  by  the  fluid,  in  order  that  the  skin  puncture  may  conform  to 
that  of  the  wall  after  the  latter  is  lowered  following  relief  from  the  disten- 
tion. Especially  is  this  important  in  the  instance  of  empyema  when  per- 
manent and  well-directed  drainage  is  needed.  The  point  of  the  needle  will 
impinge  on  the  rib  unless  care  be  exercised,  especially  if  the  intercostal  space 
be  narrowed.  The  lower  the  seat  of  puncture  the  greater  should  be  the 
upward  direction  of  the  needle  to  avoid  the  diaphragm.  If  the  tube  becomes 
blocked,  reverse  the  current  or  remove  the  obstruction  with  a  stylet.  If, 
before  insertion,  the  needle  be  passed  through  a  thin  piece  of  firm  rubber, 
the  rubber  will  be  pushed  along  the  needle  by  the  insertion,  and  accurately 
mark  the  distance  to  the  pus,  on  withdrawal  of  the  puncturing  agent. 

The  Remarks. — A  general  anesthetic  is  rarely  admissible.  The  sudden 
appearance  of  blood  in  the  fluid  may  depend  either  on  rupture  of  the  vas- 
cular adhesions,  perhaps  wound  of  the  lung  and  possibly  of  a  vessel  of  the 
thoracic  wall.     Violent  cough  not  infrequently  attends  the  flow,  due  to  un- 


1022 


OPERATIVK  SURGERY. 


'imm 


Pig.  1247.— Instruments  employed  in  operations  on  the  chest  wall  and  the  pericardium. 

a.  Large  and  small  scalpels,  b.  Pi'obe  and  blunt-pointed  bistouries,  c.  Silver  probe 
d.  Grooved  director,  e.  Sinus  forcei>s.  /.  Needle  holder,  g.  Rugine.  h.  Spatula. 
t.  Periosteal  elevator.  /.  Steel  sound,  k.  Aspirating  syringe.  /.  St.  John's  cos- 
totome.  m.  Beck's  costotome.  n.  Gigli-Uaertel  saw.  o.  "Angular  bone-cutting  for- 
ceps, p.  Rongeur,  q.  Long  blunt  scissors,  straight,  and  curved  on  the  flat.  ;•. 
131unt  and  hooked  retractors.  Forcipressure,  thumb  and  mouse-toothed  forceps, 
igatures,  suturing  needles,  drainage  tubes,  wipes,  etc.,  are  required.  An  electric 
light  inav  be  needed. 


UrEKATlU.NS   ON     Till':   'J'll(»liAX. 


1023 


fold  ill*]:  of  the  compressed  lung,  and  during  the  jittack  the  end  of  the  instru- 
ment shoukl  be  directed  as  far  as  possible  away  from  the  lung.  The  punc- 
turing agent  should  be  of  sunicieut  sisce  to  permit  the  free  escape  of  the 
fluid,  and  even  then  the  lodgment  of  the  end  in  a  caseous  mass  may  mislead 
the  operators,  unless  the  obstruction  be  pushed  aside  or  its  presence  deter- 
mined by  a  probe  carried  through  the  lumen  of  the  instrument. 

The  evacuation  of  pus  by  this  method  of  practice  can  not  be  regarded  as 
curative  in  chronic  and  tubercular  cases,  and  at  best  should  be  employed 
only  as  a  temporary  expedient  to  meet  urgent  demands.  The  very  young, 
and  those  much  enfeebled,  and  in  whom  rapid  and  large  collections  of  pus 
are  present,  may  be  more  satisfactorily  and  safely  treated  by  a  i)reliniinary 
operation  of  this  character. 

T//e  Jicsulfs. — In  acute  cases  in  children  with  pneumonia,  about  20  per 
cent  are  cured  (Holt). 

Thoracotomy. — The  operation  of  thoracotomy  is  usually  limited  to  the 
removal  of  a  portion  of  one  or  two  ribs,  for  the  purpose  of  evacuating  the 
pleural  cavity  of  pus  or  blood,  and  for  the  removal  of  diseased  processes  of 
the  chest  wall  and  lung  (Fig.  1248). 

The  Excision  of  a  Portion  of  a  Rih  for  Empyema.— It  seems  proper  to 
note  in  this  connection  that  collections  of  pus  in  the  pleural  cavity  are  fre- 
quently localized,  and  even  multiple  collections  sometimes  are  present.  This 
plan  of  action  is  especially  valuable  in  cases  with  foul  discharge  and  in  those 
of  a  chronic  nature  with  and  without  contraction  of  the  chest  wall.  The 
operation  is,  however,  severer  than  that  of  simple  incision,  and  therefore  in 
the  feeble  and  very  young  it  should  be  selected  with  discretion. 

The  Operation. — After  proper  stimulation  and  thorough  antiseptic  pre- 
cautions, place  the  patient  on  the  back  with  the  affected  side  at  the  edge  of 
the  table;  employ  local  or  general  anesthesia,  as  the  condition  of  the  patient 
requires ;  select  the  sixth  or  seventh  rib ;  make  an  incision  in  a  line  of  the 
axilla  about  two  or  three  inches  in  length  down  upon  the  middle  of  the  rib 
(Fig.  1248)  in  the  long 
axis,  through  the  peri-  r 

osteum ;  bisect  the  pri- 
mary incision  at  tlie 
center  with  a  horizontal 
one  the  width  of  the 
rib ;  raise  from  the  bone 
on  both  surfaces  (Fig. 
1249)  with  a  perioste- 
otome  the  periosteum 
together  with  its  sur- 
rounding tissues,  being 

careful  not  to  open  into  the  pleural  cavity ;  exsect  an  inch  or  an  inch  and  a 
half  of  the  bone,  dividing  it  with  a  Gigli-Haertel  saw  (Fig.  1247,  n)  or  rib 
forceps ;  arrest  htemorrliage  and  then  make  a  suitable  opening  through  the 
intervening  structures  into  the  pleural  cavity  (Fig.  1250),  and  permit  the 
fluid  to  escape  without  special  interference. 


Fig.  1248. — The  operation  of  thoracotomy,  removal  of  seg- 
ment of  rib.  a.  Incision  through  periosteum  of  rib, 
b.  Intercostal  muscle,  c.  Superficial  tissues,  dotted  line 
indicates  transverse  incision  of  periosteum. 


1024 


OPERATIVE   SURGERY. 


Fig.  1249. — The  openitiuii  of  thoracotomy,  removing 
periosteum  from  rib.  a.  Integument  and  subcu- 
taneous tissues,  b.  Intercostal  muscles,  c.  Peri- 
osteum,   d.  The  rib.    e.  Periosteotome.    /.  Forceps. 


The  Precautions. — Avoid  division  of  the  intercostal  vessels,  for  obvious 
reasons.  Irrigation  is  dangerous  and  ought  not  to  be  practiced  except  cau- 
tiously, and  then  only  for  the  relief  of  foul  discharges.  The  use  of  peroxide 
of  hydrogen  should  be  avoided  in  every  instance;  normal  saline  and  boric- 
acid  solutions  are  the  best  for 
the  purpose.  Submersion  of 
the  patient  in  a  warm  saline 
bath  affords  an  easy,  comfort- 
ing, and  effective  method  of 
washing  out  the  cavity.  The 
precautions  of  thoracentesis 
for  hydrothorax  are  pertinent 
in  this  procedure.  If  the 
opening  be  made  too  low,  the 
ascent  of  the  diaphragm  will 
obstruct  and  possibly  may 
close  it.  If  too  high  the  angle 
of  the  scapula  will  obstruct 
the  opening.  The  lymph 
masses  may  be  loosened  by 
introduction  of  the  finger  or 
a  sound,  and  removed  with 
forceps  whenever  they  obstruct  the  opening.  The  drainage  tube  should  be 
incompressible,  should  just  reach  the  pleural  cavity,  and  be  fastened  so  that 
it  can  not  escape  within.  Sometimes  two  are  employed  (Fig.  1251)  side  by 
side,  especially  when  washing  of  the  cavity  is  practiced  during  healing,  the 
fluid  entering  one  and  escap- 
ing by  the  other.  If  the  tube 
happens  to. rest  upon  an  in- 
tercostal nerve  severe  pain, 
referable  to  the  distribution 
of  the  nerve,  often  occurs. 
The  fluid  should  be  permit- 
ted to  escape  slowly  and 
ought  to  be  temporarily  ar- 
rested in  case  of  severe  cough- 
ing. If  haemorrhage  happen 
into  the  pleural  cavity,  the 
tube  should  be  introduced, 
the  wound  dressed,  and  the 

patient  placed  on  the  diseased   p^,,  lor.o.-Opening  into  the  pleural 
side  at  once.  vided  end  of  rib.     b.  The  pleura. 

The  Remarks. — It  is  wise 
that  a  bacteriological  exam- 
ination of  the  pus  be  made,  to  determine,  as  far  as  possible,  the  nature  of 
the  process.  The  drainage  tubes  should  not  be  so  long  as  to  impinge  on 
the  lung,  and  ought  to  be  shortened  as  the  cavity  contracts. 


d.    IMuscular  tissue, 
neous  tissues. 


cavity,     a.  Di- 
c.  Periosteum. 
Inteffument  and  subcuta- 


OlM'lKA'I'lo.NS   ON    'IllK   TIlolfAX.  1025 

The  Aflcr-lrcdlnicnl. — Antisi'plic  drcsaiiig  slioiild  be  applied  liberally  to 
the  seat  of  the  operation,  and  eluinged  frequently  to  avoid  infection.  'I'lie 
patient  should  bo  kept  quiet,  and  indications  of  treatment  met  as  they  arise. 
A  sinus  formation  may  be  irrigated  and  generally  treated  as  in  other  parts 
of  the  body.  Gymnastic  exercise  and  efforts  directed  to  the  prevention  of 
contraction  of  the  chest  should  be  practiced. 

If  for  removal  of  diseased  bone,  make  an  incision  at  the  middle  of  the 
long  axis  of  the  rib  (Fig.  1^48)  of  sulUcient  length  to  include  the  diseased  por- 
tion. Supplement  this  one  at  the  center  by  a  transverse  incision.  Separate 
the  periosteum  along  with  the  superimposed  tissues,  liberate  the  bone,  and 
raise  it  from  its  bed.  If  tlie  sequestrum  be  not  loose,  time  should  be  allowed 
for  its  separation. 

Simple  Incision. — Simple  incision  with  drainage  is  not  now  regarded 
with  the  same  favor  as  formerly.  The  narrowness  of  the  opening  and  its 
tendency  to  close  and  hinder  drainage  are  serious  objections  in  chronic 
cases,  and,  moreover,  the  opportunity  for  escape  of  the  fibrinous  products 
from  the  chest  and  the  ability  to  properly  remove  them  present  objection- 
able features  to  the  use  of  the  method.  But  in  limited  collections  of  pus  of 
an  acute  nature,  and  chronic 
cases  in  feeble  patients,  this  >w^ 

method,  if  failing  to  cure,  \    \ 

may  often  serve  an  impor- 
tant preliminary  purpose. 
The  establishment  of  the 
proper  seat  of  the  operation 
and  the  precautions  attend- 
ing the  procedure  differ  in 

no    essential    respect    from     ^^        „-       -r     .  .  ,  , ,         , 

,,  J,  .      ,.  ,      ^      Yiv,.  12.j1. — Drauisi"'e  of  CHVitv  with  two  rubber  tubes, 

those  of  aspiration  and  of  ^oft  p^i-ts  sutured. 

excision  of  a  rib.  The  in- 
cision is  made  midway  between  the  contiguous  borders  of  the  ribs,  either  in 
the  axillary  or  subscapular  line,  as  best  suits  the  purpose,  always  remembering 
(as  in  the  other  operations)  to  avoid  locating  it  so  that  the  movements  of  the 
scapula  or  diaphragm  can  interfere  with  drainage.  The  incision  is  cautiously 
made  down  upon  the  pus,  instead  of  entering  the  collection  at  once  by  a 
sudden  thrust.  The  latter  plan  is  unnecessary  and  needlessly  dangerous. 
After  the  escape  of  the  fluid  and  of  the  lymph  products,  drainage  is  estab- 
lished as  in  the  preceding  operations.  However,  the  strong  inclination  of 
the  opening  to  close  because  of  the  approximation  of  the  ribs  requires  that 
the  drainage  agent  shall  not  infrequently  have  rigid  walls.  To  meet  this 
indication  we  have  in  several  instances  utilized  for  the  purpose  the  ordinary 
large-sized  gutta-percha  (Fig.  1270,  /)  tracheotomy  tube,  properly  shortened, 
through  which  a  rubber  tube  is  carried.  If  the  former  be  heated  over  an 
alcohol  lamp,  it  can  be  cut  off  or  bent  in  a  direction  to  suit  the  demands  of 
drainage  and  of  protection  to  the  lung  at  the  same  time.  The  collar  of  the 
tube  fits  closely  to  the  side  of  the  chest  and  can  be  held  in  place  by  means 
of  an  elastic  tape  fastened  around  the  body.     The  removal  from  the  upper 


1026 


OPERATIVE   SURGERY. 


border  of  the  contiguous  lower  rib  witli  a  rongeur  of  a  limited  portion  of 
bone  sufficient  to  afford  lodgment  of  the  hard-  or  of  a  soft-rubber  tube  pre- 
vents pressure,  and  also  obviates  the  closure  of  the  latter. 

Tlie  Remarks. — One  opening  is  sufficient,  and  this  need  not  be  made  at 
the  most  dependent  part  of  the  collection,  as  the  lung  expansion  and  dia- 
phragmatic ascent  expel  the  pus.  The  tube  should  be  of  fresh  rubber  at 
all  times  and  be  securely  anchored  with  a  safety  pin.  It  should  not  reach 
within  half  an  inch  or  so  of  the  inner  wall  of  the  abscess  cavity,  and  the 
rapidity  of  the  contraction,  as  ascertained  by  the  introduction  of  water, 
should  regulate  the  frequency  and  amount  of  the  shortening  of  the  tube. 
The  tube  should  be  removed  when  only  a  small  amount  of  sero-purulent 
fluid  escapes. 

llie  Results. — Incision  and  drainage  and  primary  excision  give  different 
results.  The  former  a  death  rate  of  about  33,  the  latter  about  20  per  cent. 
In  467  cases  treated  by  both  methods,  the  average  mortality  was  26  per  cent. 
The  following  tabulated  statement  of  123  cases  of  empyema  in  childhood  is 
very  instructive : 


Results  of  Operations  of  Empyema  in  ChildJiood.     (B? 

others.) 

No.  of  cases. 

Recoveries. 

Deaths. 

Siinple  aspiration   

9 
98 
9 
2 
5 

2 

64 

8 
2 
5 

Simple  incision  with  drainage 

14 

The  same  after  unsuccessful  aspiration..  . 
Primary  exsection 

1 
0 

Secondary  exsection 

0 

123 

81 

21 

Aspiration  combined  with  Drainage. — Much  has  been  said  in  the  past  of 
aspiration  for  the  purpose  of  expansion  of  the  lung  and  drainage  in  empy- 
ema. Potain,  Perthes,  Biilau, 
and  others  devised  methods  of 
relief,  most  of  which  were  im- 
practicable because  they  were 
too  confining  and  cumbersome. 
The  writer  during  the  last  year 
devised  and  applied  success- 
fully to  the  chest  of  a  patient 
suffering  from  an  extensive 
traumatic  empyema*  the  fol- 
lowing simple  and  effective  ap- 
paratus (Fig.  1252) :  the  end 
of  the  tube  projecting  beneath 
the  cushion  (a)  is  passed  into- 
Fig.  1252.-The  aspiration  apparatus  «.  Hollow  ^j  empyemic  cavity  a  proper 
rubber  cushion,      o.    Distended  rubber  bag.     c.  ^  -^  .7        r     r 

Stopcock,    d.  Glass  observation  tube.  distance,  and  the  cushion  (a)  is 


*  From  the  Jacobi  Festschrift. 


OPEKA'I'loNS   (»N    'I'lIK   'I'lIoKAX. 


1027 


placed  ill  contact  witli  the  wall  of  the  tiiorax  in  such  a  niaiiner  as  to  com- 
niuml  e(jnally  the  area  surrouiuling  the  opening  into  the  i)leural  cavity.  The 
nozzle  of  an  onlinary  six-ounce  rubber  syringe  is  tiien  inserted  into  the  dis- 
tal end  of  the  tube  (Fig. 


Fi(i.  12r)o. — Aspiration  of  the  cavity,     a.  The  p^lass  obser- 
vation tube,  showing  suction  force  applied  by  syringe. 


1'2^}'3),    the    li(|uid    with- 
drawn,   followeil     linally 

by   sntlicient    exhaustion 

of    the  air   to  cause  the 

rubber     cushion     to     fit 

closely    enough     to     the 

chest  wall  to  prevent  the 

passage  of  air  beneath  it 

into    the   pleural   cavity. 

The    stopcock     is     then 

closed    (Fig.    l;25-4),    the 

syringe  removed,  and  the 

nozzle  of  tlie  rubber  bag 

(Fig.  12b2,b)  while  fully 

collapsed  is  inserted  firm- 
ly into  the  open  end  of 

the  tube  (Fig.   1255),  the  stopcock  reversed,  thus  establishing  aspiration, 

which  is  maintained  so  long  as  the  bag  is  expanding.     The  chest  is  then 

dressed  and  the  apparatus  duly  fastened  in  place  as  indicated  in  Fig.  1256. 

The  patient  can  go 
about  comfortably 
with  the  apparatus 
in  action  without  at- 
tracting special  at- 
tention. AVhen  the 
bag  is  nearly  dis- 
tended, the  stopcock 
should  be  closed,  the 
bag  cleansed,  again 
collapsed,  reapplied, 
and  the  stopcock 
opened. 

The  Precautions. 
— If  brisk  and  forci- 
ble asjiiration  by  the 
syringe  be  made,  the 
tube     will    collapse 

Fig.  1254.— Aspiration  of  the  cavity,     a.  Segment  ot  glass  lube.    (Fig.      1253),      and 
Cavity  aspirated  and  stopcock 'closed  to  prevent  admission    ^^^^^  ^|jg  discharo-e 

will  be  tinged  with 
blood,  which  can  be  noted  through  the  glass  segment  of  the  tube.     Continu- 
ous and  mild  aspiration  is  safer  and  quite  as  effective  as  the  vigorous  in  the 
majority  of  instances.     The  degree  of  distention  of  the  bag  should  be  fre- 
71 


1028 


OPERATIVE  SURGERY. 


Fig.  1255 — Aspiration  of  cavity.     The  collapsed   rubbei   bag 
attached  and  stopcock  opened  ;   the  apparatus  in  action. 


quently  observed  in  order  that  it  may  be  removed,  cleansed,  and  reapplied 
without  the    interruption  of  aspiration.      Adhesive  ])laster  applied  to  the 

chest  around  the 
opening  aids  in  the 
exclusion  of  air. 
Absorbent  cotton 
thoroughly  wet  with 
a  boric-acid  solution 
hinders  the  passage 
of  air  beneath  the 
cushion.  It  is  very 
important  in  this 
connection  to  re- 
member that  the  cot- 
ton, or  any  small 
movable  body,  may 
be  drawn  into  the 
chest  unless  care  be 
exercised.  Should 
this  happen  it  can 
be  removed  quite 
readily  in  most  in- 
stances by  moving  around  in  the  cavity  the  inner  end  of  the  tube  while 
making  suction  on  the  outer  with  the  syringe. 

The  Results. — In  the  case  to  which  aspiration  was  applied  it  acted  effi- 
ciently and   promptly, 
and  was  easily  managed 
by  the  patient. 

Hutton  has  devised 
an  ingenious  and  serv- 
iceable apparatus  which 
permits  the  escape  of 
fluid  from  and  pre- 
vents the  entrance  of 
air  into  the  pleural  cav- 
ity during  the  acts  of 
breathing,  coughing, 
etc.  The  apparatus 
consists  of  a  large  rub- 
ber drainage  tube  with 
a  flange  of  sheet  rub- 
ber five  inches  long  and 
four  inches  broad  ;  the 
tube  passes  through  the 
middle   of   the   flange. 


■'ii||yi\\4w 

Fig.  1256. — Aspiration   of  cavity.      The  tiressiiigs  applied; 
apparatus  held  in  place  by  safety  pins  while  in  action. 


A  valve  of  duckbill  form  is  made  by  slitting  a  gutta-percha  nipple  at  the 
end.     The  unslit  portion  of  the  nipple  is  connected  by  means  of  a  glass 


Ol'KUA'riONS   ON    TllK   TIlUllAX.  102<J 

tube  with  a  short  piece  of  rubber  tube,  which  hitter  is  finully  connected  with 
the  nuiin  tube  by  nieiuis  of  a  riglit-iuij^'knl  ghiss  one.  After  the  chest  is 
opened  the  remaining  end  of  the  primary  tube  is  cut  olf  near  enough  to  the 
flange  to  permit  it  to  extend  only  tiirough  the  chest  walL  The  apparatus 
is  then  bouiul  firmly  in  })lace,  the  Hange  resting  upon  a  large  piece  of  wet 
gutta-percha  tissue  to  prevent  tlie  entrance  of  air  beneath.  Ilutton  speaks 
in  high  terms  of  this  device. 

It  seems  to  tlu'  writer  that  ]n-acticable  aspii-atidu  olTcrs  the  o])])ortunity 
of  prompter  cure  in  excision  cases,  and  not  impossibly  may  render  needless 
the  serious  methods  of  practice  by  obviating  the  conditions  that  prompt 
their  use.  Much  contentiou  has  arisen  in  the  past  regarding  its  feasibility. 
The  writer  notes  with  regret  the  seemingly  strenuous  tenor  of  these  conten- 
tions. Cases  complicated  with  gangrene  of  the  lung  and  abundant  fibrinous 
deposits  iire  certainly  unsuited  for  the  immediate  use  of  aspiration  treat- 
ment. 

Thoracoplasty. — Estldnder\s  Operation. — The  operative  practice  associ- 
ated with  the  name  of  Estliinder  is  applicable  to  the  long-standing  cases  of 
empyema,  in  which  the  powers  of  a  natural  cure  are  inadequate  for  the  purpose, 
and  draining  by  incision,  or  the  excision  of  a  limited  portion  of  one  or  more 
ribs,  has  failed  to  afford  relief.  The  size  and  extent  of  tbe  abnormal  cavity 
should  be  estimated  with  the  finger  or  probe,  or  by  the  means  of  fluid  injec- 
tion. An  incision  made  along  the  center  of  an  intercostal  space  affords 
opportunity  for  removal  of  two  contiguous  ribs  ;  two  corresponding  incisions, 
the  removal  of  four  ribs,  etc.  (Estliinder).  The  soft  parts  overlying  the  ribs 
of  the  outer  wall  of  the  cavity  are  raised  as  a  single  flap,  or  two  or  three  small 
flaps  are  formed  (Jacobson),  according  to  the  size  of  the  cavity,  condition  of 
the  patient,  and  the  predilection  of  the  operator.  The  smaller  the  flap  the 
less  is  the  ha3morrhage  and  shock ;  and,  too,  if  the  first  flap  be  centrally 
located  and  the  rib  removed,  further  procedure  at  that  time  can  be  deferred, 
if  need  be,  and  yet  the  patient's  condition  will  have  been  improved  by  the 
i:)rimary  measure.  With  the  large  flaj)  these  considerations  are  scarcely 
applicable.  After  exposure  of  the  ribs  by  either  method,  they  are  separated 
from  tbe  remaining  soft  tissues,  by  means  of  a  slightly  curved  elevator,  to 
the  full  extent  of  the  cavity,  and  divided  at  the  limits  of  exposure  with  a 
fine  saw  or  bone-cutting  forcej^s,  and  removed.  The  periosteum  should  be 
removed  either  witli  or  following  the  enucleation  of  the  rib. 

The  llemarTcs. — Unless  in  all  radical  methods  the  thickened  parietal 
pleura  of  old  cases  and  the  associated  tissues  are  removed  along  the  line  of 
bone  section,  and  the  empyemic  cavity  is  thoroughly  exposed,  scraped, 
cleansed,  wiped  out,  drained  at  the  dependent  portions,  and,  if  need  be, 
lightly  packed  with  aseptic  gauze,  satisfactory  relief  need  not  be  expected. 

Schede's  operation  is  applicable  to  all  cases  with  greatly  thickened  pleura. 
In  this  method  a  U-shaped  incision — beginning  in  front  at  the  outer  edge 
of  the  pectoral  muscle,  on  a  level  with  the  axilla  (fourth  rib),  extending 
below  to  the  lowest  limit  of  the  pleura  (tenth  rib),  and  behind  up  along  the 
vertebral  border  of  the  scapula  to  the  second  rib  (Fig.  Vlbl) — is  made  down 
to  the  bony  frame  of  the  chest.     This  flap  is  dissected  from  the  ribs,  and  the 


1030 


OPP]RATIVE   SUROERY. 


scapuhi  aiul  the  sub.scapnlaris  muscle  are  raised  from  the  trunk.  The  ribs 
from  the  second  downward  are  resected  subperiosteally  from  the  costal  car- 
tilages to  the  tubercles.  The  intercostal  structures  and  the  pleura  are  re- 
moved with   larire  blunt  scissors,  and   the  surface  is  curetted,  thoroughly 

cleansed,  the  flap  replaced,  and  the  borders 
are  united  together,  with  the  expectation  of 
securing  primary  union. 

The  Comments. — The  scapula  should  be 
drawn  forward  out  of  the  way  as  the  posterior 
incision  is  made.  After  removal  of  the  ribs, 
the  remaining  tissues  are  cut  away,  beginning 
at  the  fistulous  opening,  if  one  be  present, 
and  passing  to  divide  the  posterior  border 
first,  thus  reducing  the  bleeding  to  a  mini- 
mum. Pinching  of  the  vessels  between  the 
thumb  and  fingers  before  division  will  lessen 
the  loss  of  blood.  The  return  of  the  flap  to 
the  opening  often  leaves  an  incomplete  closure 
above,  which,  however,  finally  heals. 

DeJorme  forms  an  osteoplastic  fla])  extend- 
ing from  the  third  to  the  sixtli  rib,  with  the 
pedicle  above  and  posteriorly  (Fig.  963).     In 
front  the  ribs  and  intercostal  tissues  are  sev- 
at  the  upper  and  lower  borders  the  intercostal  tissues,  behind  the  ribs. 


Fig.  1257. — The  operation  of  thora- 
coplasty, Schede's  method. 


I'ed 


are  divided  and  perliaps  resected  to  a  limited  extent,  and  the  flap  is  turned 
backward.  The  surfaces  are  thoroughly  curetted,  cleansed,  and  freshened, 
and  apposed  by  returning  the  flap  in  place  and  uniting  its  borders  with 
sutures. 

If  the  periosteum  be  left  behind  along  with  the  parietal  pleura,  etc.,  care 
should  be  taken  to  keep  the  tissues  in  apposition  to  the  walls  of  the  cavity, 
or  the  rapid  development  of  the  new  bone  may  negative  the  attempt  at  cure. 
If  one  flap  ouh'  be  made  it  is  usually  of  an  oval  (Schede)  or  rectangular 
form  (Delorme),  with  the  base  upward  to  facilitate  drainage.  A  single 
vertical  incision  (Gould)  with  lateral  displacement  and  retraction  of  the 
tissues  can  be  employed  if  the  cavity  be  somewhat  narrow.  Fenger  prac- 
tices the  removal  of  rib  fragments  of  diminishing  lengths,  beginning  at  the 
center  of  the  cavity  in  those  in  which  the  transverse  diameter  is  the  great- 
est at  that  point.  If  the  vertical  diameter  be  the  greater,  this  surgeon  prac- 
tices the  same  plan  of  procedure,  only  much  shorter  portions  are  removed, 
for  obvious  reasons.  The  second  rib  is  rarely  resected,  on  account  of  its  high 
position  and  the  greater  importance  of  its  anatomical  associations.  The 
first  rib  is  of  still  greater  significance  in  these  respects,  and  should  be  let 
alone,  except  in  the  rarest  of  instances.  From  the  third  to  the  seventh 
inclusive  are  the  ribs  usually  resected,  and  from  the  tubercles  to  the  carti- 
lages, if  need  be.  In  extensive  excision  the  shock  may  be  great,  and  the 
deformity  will  be  pronounced.  The  lung  will  not  resume  the  usual  position, 
but  the  parietal  soft  parts  will  oV)literate  the  cavity,  if  adhesion  to  the  lung 


oPKiJATioxs  OX  'nil':  'riioii.w.  1031 

be  secured.  A  sinus  of  uuKK'rute  exlciit  nuiy  folKjw,  csitccially  if  the  apex 
of  tlie  cavity  be  not  likewise  occlutled. 

If  the  patient  have  tubercular  disease  the  outlook  is  iiiucli  iinp.iiici],  and 
the  siini)ler  methods  are  advisal)le,  at  least  as  preliniiiiary  measures.  Each 
case  must  Ite  estimated  aci'ording  to  its  as.sets,  as  to  the  variety,  extent,  and 
time  of  opcraiioii,  and  as  to  whet-hei-  an  extensive  procedure  be  made  at  all. 
All  of  the  unyieldin^i;"  Ixmy  wall  should  be  removed  in  every  instance,  if  cure 
is  to  be  expected. 

The  After-treatment. — Gymnastic  exercise  and  forced  expiration  (breath 
gymmistics)  constitute  the  main  measures  directed  to  restoration  of  symmetry. 
High  elevations  exercise  a  curative  influence. 

Tlie  liesuJts. — The  deformity  is  not  cured,  and,  in  fact,  is  increa.sed  by 
the  o])eration,  but  may  diminish  later.  The  danger  of  amyloid  degeneration 
is  obviated,  and  substantial  cure  may  arise.  The  shock  is  often  great,  and 
corresponding  care  should  be  exercised  to  avoid  an  unfavorable  issue  from 
this  cause. 

Caries  and  Necrosis  of  the  Ribs  and  Sternum. —  Thoracotomy  is  practiced 
for  the  relief  of  this  condition,  and  commonly  with  eminent  success.  Caries 
and  necrosis  of  these  structures  follows  sometimes  injury,  resection,  syphilis, 
and  typhoid  fevers.  The  ribs  from  the  fourth  to  the  eighth  are  most  often 
diseased,  and  usually  near  the  middle  portions.  Such  complications  as  em- 
pyfemia,  burrowing  of  pus,  causing  abscess  at  distant  situations — i.  e.,  of  the 
back,  abdominal  wall,  and  even  remoter  parts — are  noted.  Rarely  indeed 
are  the  pleural  cavity  and  lung  secondarily  involved.  The  seat  of  the  dis- 
ease of  the  rib  is  usually  characterized  by  the  presence  of  an  abscess  or  of 
a  sinus.  Usually  operative  relief  is  simple  and  effective.  A  horizontal, 
straight,  or  a  T-shaped  incision  is  made  over  the  seat  of  the  disease,  the  skin 
and  muscles  are  conjointly  reflected,  the  abscess  is  isolated,  preferably  with- 
out opening  it,  and  dissected  away,  followed  by  cleansing  of  the  parts  with 
an  antiseptic  solution.  A  free  incision  is  made  down  upon  the  long  axis 
of  the  diseased  bone  (Fig.  1248)  in  the  line  of  a  sinus  when  present,  the 
extent  of  the  disease  is  determined,  the  bone  exposed  and  cut  off  outside 
of  the  affected  limits,  preferably  with  a  Gigli-Haertel  saAv  (Fig.  1247,  n),  per- 
haps with  a  bone  forceps.  The  diseased  bone  is  removed,  the  associated 
morbid  products  dissected  and  scraped  away,  the  parts  thoroughly  flushed 
with  an  antiseptic  solution,  the  flaps  returned  to  place,  and  the  borders 
sutured  together  with  catgut.  In  the  instance  of  the  sternum  the  fistul^e 
are  slit  up  in  the  line  best  intended  to  secure  good  observation  and  drainage 
of  the  diseased  area.  The  diseased  products  are  cautiously  removed  by 
means  of  the  trephine,  periosteotome,  bone  gouges,  scoops,  etc.  (Fig.  327), 
remembering  that  the  anterior  mediastinum  may  have  been  invaded.  The 
posterior  surface  of  the  sternum  may  be  diseased  more  extensively  than  at 
first  seems  apparent.  Abscess  and  sinus  associated  with  caries  and  necrosis 
of  those  structures  should  be  carefully  sought  for,  scrupulously  cleansed  by 
scraping  and  douching,  and  independently  drained. 

The  Remarks. — The  preservation  of  the  upper  end  of  the  sternum  is 
especially  significant  because  of  its  mechanical  association  with  the  ends  of 


1032 


OPERATIVE  SURGERY. 


the  clavicle.  Disease  of  tlie  posterior  surface  of  the  sternum  is  apt  to  be 
insidious,  and  may  become  quite  extensive  and  pus  point  even  at  the  inter- 
costal spaces  at  the  sides  before  the  gravity  of  the  cases  is  fully  appreciated. 
The  fact  that  the  pericardium  may  be  intimately  associated  with  the  pos- 
terior surface  of  the  bone  suggests  care  in  the  manipulations  incident  to  the 
treatment  of  the  bone  and  mediastinal  abscess. 

Tlie  Rcs'hUs. — The  immediate  results  of  operative  treatment  are  highly 
favorable.  Final  cure  is  often  much  delayed  because  of  the  frequently  spe- 
cific nature  of  the  trouble,  the  inac- 
cessible locations  of  the  disease,  and 
the  tortuous  outlines  of  the  sinuses, 
to  say  nothing  of  the  complications 
of  an  organic  cliaracter. 

Tumors  of  the  Ribs  and  Sternum. 
— The  primary  tumors  of  these  struc- 
tures are  comparatively  infrequent, 
the  secondary  are  exceedingly  rare. 
Tumors  of  an  innocent  nature,  and 
those  limited  to  the  bones  and  car- 
tilages, are   not,  as  a  rule,  difficult 
to   remove ;   but  those  of   extensive 
growth,  especially  of  a  malignant  na- 
ture,   present     frequently    complex 
problems  and  insurmountable  obsta- 
cles to  removal  for  con- 
sideration.    Thorough 
asej)tic     method     and 
free   exposure    of    the 
seat  of  disease  are  es- 
sential elements  of  the 
technique.      A    large, 
oval,  musculo  -  cutane- 
ous flap,  with  depend- 
ent convexity,  located 
so  as  to  facilitate  obser- 
vation and   manipula- 
tion, should  be  made. 
The  bone  is  severed  at 
the  outer  limits  of  the 
.rat us  in  action,  showing    ^-^^^.^^^  ^    ^^^^   forceps, 
ntiibiition  eone.s,  and  the  •  ^ 

or   chisel    and    mallet 

(Fig.  327),  and  cau- 
tiously raised,  along 
with  the  morbid  growth 
from  tlie  body,  by 
means  of  careful  dissection.  If  the  growth  is  malignant,  the  extent  is 
problematical,  and  the  possibility  of  complete  removal  is  uncertain.     Exten- 


FiG.  1258.— The  FcH-O'Dwm  i  ,(| 
the  bellows,  nsMJiJcd  si/(«x  dl 
conductor.  An  intul).il  ion  cone  ot  suitable  size  is  pi-essed 
into  tiie  larynx  so  as  to  prevent  the  escape  of  air  between 
it  and  the  laryngeal  wall.  The  bifurcated  ari-angenient 
of  the  conductor  regulates  the  amount  of  air  introduced 
by  means  of  the  thumb  acting  as  a  valve  at  the  point  of 
escape. 


Ol'KRATlUNS   ON    THE  THORAX.  1033 

sive  areas  of  disease  involving  the  sternum,  ribs,  pleura,  and  even  the  peri- 
cardium, have  been  successfully  removed  and  tlie  patients  have  recovered. 
An  important  feature  of  the  removal  of  these  growths  relates  to  whether  or 
not  the  disease  is  extrapleural  or  intrapleural.  In  the  former  instances  the 
danger  of  ()])erative  involvement  of  the  pleural  cavity  is  a  matter  largely 
uiuler  the  control  of  the  surgeon,  wlio,  by  the  employment  of  judicious  fore- 
thought and  cautious  technique,  will  rarely  indeed  invade  this  cavity  unless 
the  pleura  itself  be  involved  in  the  disease.  When,  however,  the  removal  of 
malignant  growths  is  attempted,  the  invasion  of  the  pleural  cavity  must 
necessarily  be  frequent  and  often  extensive  if  practical  benefit  is  to  follow 
operative  practice.  Therefore,  the  special  dangers  of  sudden  and  persistent 
j)neumothorax,  of  haemorrhage,  of  shock,  of  infective  pleuritis,  etc.,  force 
themselves  at  once  to  the  front.  The  prevention  and  successful  control  of 
the  grave  consequent  complications  of  these  operations  is  a  matter  of  pro- 
nounced importance.  Shock  and  haemorrhage  are  the  dangerous  features  in 
operations  in  cases  of  non-pleural  involvement.  They  should  be  anticipated 
and  met  along  the  lines  that  characterize  their  presence  in  operations  on 
other  parts  of  the  body.  In  intrapleural  involvement,  pneumothorax,  haemor- 
rhage, and  shock  are  serious  complications,  and  the  first  is  truly  formidable 
when  suddenly  occurring  in  the  presence  of  either  of  the  others.  However, 
it  ought  to  be  recognized  tiiat  not  infrequently  little  or  no  special  disturb- 
ance attends  surgical  invasion  of  the  pleural  cavity  in  those  cases.  Parhani's 
investigations  show  that  "  little  or  no  disturbance  "  follow^ed  in  about  40  per 
cent,  "moderate  disturbance"  in  about  24  per  cent,  and  "quite  stormy 
manifestations,  even  threatening  life,"  in  about  36.5  per  cent  of  the  cases  in 
which  the  pleural  cavity  was  opened.  The  larger  the  hole,  and  the  longer 
time  it  remained  open,  the  severer  were  the  effects.  The  severe  manifesta- 
tions occurred  in  pneumothorax  of  the  right  side  nearly  twice  as  often  as  in 
that  of  the  left.  Parham's  investigations  emphasize  the  practical  wisdom 
of  operating  before  involvement  of  the  pleura,  of  establishing  preliminary 
adhesion  of  the  surfaces  by  sewing,  etc.,  of  prompt  closure  of  the  tear  by 
the  finger,  by  a  compress,  or  suture.  Keen  closed  the  opening  in  the  pleura 
by  stitching  the  lung  to  the  border. 

Tlie  induction  of  extrapleural  hydrothorax  (page  1045)  and  of  deep  in- 
S]iiration  with  final  closure  of  the  w^ound  are  available  methods  of  treatment. 

Matas  and  Parliam  regard  the  Fell-0'Dwyer  apparatus  (Figs.  1258  and 
1259)  for  forced  artificial  respiration  as  an  agent  of  great  significance.  The 
Jatter  surgeon  considers  it  an  essential  part  of  the  operative  armamentarium, 
"intended  to  revolutionize  this  field  of  surgery."  Xorfhru])*  extols  the 
apparatus  as  "  an  efficient  aid  in  carrying  on  prolonged  artificial  forcible 
respiration." 

The  following  is  substantially  the  text  of  a  recent  communication  from 
Dr.  Fell  descriptive  of  the  apparatus  employed  by  him  for  the  purpose  of  in- 
ducing forced  respiration  (Fig.  1259):  "  The  apparatus  which  I  have  used  and 
found  so  efficient  in  cases  of  forced  artificial  respiration,  consists  of  a  bellows 

*  Presbyterian  Hospital  Medical  and  Surgical  Report.     January,  1896.     Vol.  I. 


1034 


OPERATIVE   SURGERY. 


(a),  the  size  of  which  has  been  determined  by  my  experience.  It  is  operated 
as  follows  :  Three  movements  for  inspiration  and  three  for  expiration.  This 
will  produce  eighteen  or  twenty  respirations  per  minute  when  worked  at  a  con- 
venient rate  of  speed.     The  attempt  to  operate  it  so  that  a  single  movement 


Fig.   1250. — Forced  artificial  respiration,  Fell's  improved  apparatus,     a.  Bellows,     b.  Air 

valve,     c.  Face  ina<k. 

represents  an  inspiration  would  almost  certainly  defeat  the  purpose  for  which 
the  apparatus  is  intended.  The  anesthetic  can  be  administered  by  placing  a 
sponge  or  gauze,  properly  saturated  with  the  anaesthetic,  over  or  in  proximity 
to  the  opening  through  which  the  air  enters  the  bellows.  A  simple  arrange- 
ment constructed  on  the  principle  of  the  chemist's  wash  bottle,  by  means  of 
which  oxygen  can  be  made  to  pass  through  a  tube 
into  the  air  valve,  thence  with  the  ansesthetic  into  the 
lungs,  can  be  attached.  This  device,  along  with  that 
for  mingling  oxygen  with  the  inspired  air,  makes  a 
complete  outfit  for  the  jiurpose.  Xext  to  the  bellows 
is  the  air  valve  (b),  with  which  it  is  arranged  to  act. 
The  operator  presses  down  the  piston  of  the  valve  a 
full  stroke  during  three  movements  of  the  bellows, 
thus  causing  inspiration  by  permitting  the  air  satu- 
rated with  the  anaesthetic  to  enter  the  lungs  through 
Fig.  1260.— The  trache-  either  of  the  selected  channels — i.  e.,  the  face  mask  (c),  ^ 
otomy  tube  and  rings  the  intubation  cone  (Fig.  1258),  or  the  tracheotomv 
used  in  forced   artifl-    .    ,       ,t^.       -,^r.r\       rm  •  ^        •     .,.1  i       „j   ,  .  ♦:i 

cial  respiration,  Fell's   ^^'"®  (^ig-   1260).     The  piston  is  then  released  until 

method.  three   movements   of    the   bellows   are   made,    which 

permits  expiration  to  occur.  Before  the  operation  is 
begun  the  mask  should  be  snugly  fitted  to  the  face  to  prevent  any  uncer- 
tainty in  this  respect.  If  during  inspiration  it  does  not  fit  so  that  the 
cheeks  may  bulge  somewhat  without  air  escaping  by  the  sides  of  the  mask, 
its  best  action  can  not  be  attained.  Frequently  a  pad  or  folded  handker- 
chief placed  over  the  bridge  of  the  nose  will  secure  a  tight  fit.     If  an  intu- 


ol'llKATIoNS   ()\    'I'lll'-    'IMIOUAX.  1035 

bation  tube  be  oinployi'd,  ;i  rubber  tube  from  tlic  air  vahc  can  be  connected 
with  the  former  ami  good  iiillation  eun  then  be  secured,  j)rovi(k'd  thiit  tlio 
end  of  the  tube  is  of  })roper  size  to  iit  tlie  trachea.  My  l)est  results  in  long- 
continued  respiration  have  been  secured  by  means  of  tracheotomy  and  the 
occluding  of  the  trachea  with  a  suitably  sized  ring  screwed  to  the  end  of  the 
tracheotomy  tube  (Kig.  1 1<><>).  But  for  ot)erative  work  on  the  thorax  the  other 
methods  a})pear  to  be  the  better  suited.  The  size  of  the  bellows  and  the 
manner  of  its  operation  should  be  suited  to  the  requirements  of  individual 
cases — i.  e.,  one  movement  for  inspiration  and  one  for  expiration  in  a  child, 
two  movements  for  inspiration  and  three  for  expiration  in  a  youth,  and  three 
for  inspiration  and  the  same  for  expiration  in  an  adult  will  usually  suthce." 

Aspiration  only,  and  aspiratory  drainage  (page  102G  et  scq.)  in  cases  of 
elTusion,  should  bo  employed. 

The  rrccantiuns. — lie  sure  and  cut  wide  of  malignant  disease,  removing 
its  manifestations  entirely  when  practicable.  Avoid  operation  in  these  cases 
when  complete  removal  is  regarded  impossible,  except  for  the  purposes  of 
euthanasia.  The  thin  pleura  lying  beneath  innocent  growths  will  be  torn 
in  their  removal  unless  great  care  be  exercised.  Hiemorrhage  is  often  pro- 
fuse in  removal  of  innocent  growths,  and  always  so  and  persistent  in  removal 
of  the  malignant. 

The  Results.— Oi  2G  extrapleural  operations,  7  died  and  19  recovered. 
Of  51  intrapleural  operations,  IG  died  and  35  recovered.  Eecurrence  fol- 
lowed within  a  year  in  7  of  10  cases  of  extrapleural,  and  in  12  of  23  cases  of 
intrapleural  opei'ations. 

Wounds  and  Hernia  of  the  Diaphragm.— Attention  to  the  attachments  of 
the  diaphragm  to  the  thorax,  and  to  the  peculiarity  of  its  structure,  is  impor- 
tant as  preparatory  to  the  consideration  of  wounds  and  hernia  of  the  organ. 
Also  its  relation  to  contiguous  viscera,  and  the  influence  exercised  on  them 
by  its  presence  and  movements,  should  not  be  overlooked.  Wounds  of  the 
diaphragm  often  escape  a  suspicion  of  their  presence,  healing  without  mani- 
fest difficulty,  or  are  revealed  either  on  autopsy  or  by  an  explorative  incision 
directed  to  the  relief  of  complicating  haemorrhage,  a  visceral  wound  or  an 
acute  intestinal  obstruction  provoked  by  strangulation  consequent  to  the 
original  injury.  The  situation,  direction,  and  extent  of  a  wound  of  the 
thorax  will  often  suggest  diaphragmatic  involvement,  while  other  evidence 
escapes  observation.  Diaphragmatic  hernia?  are  either  of  congenital  origin 
or  due  to  injury,  and  in  eitlier  instance  they  may  escape  detection  or  thought, 
until  revealed  by  autopsy  or  explorative  operation.  Hernia  from  either  of 
these  causes  happens  much  oftener  at  the  left  than  the  right  side.  Con- 
genital protrusions  occur  more  frequently  posteriorly  than  anteriorly,  and, 
as  elsewhere,  their  size  and  shape  are  regulated  by  the  characteristics  of  the 
opening.  In  only  about  10  per  cent  of  the  cases  are  the  displaced  viscera 
provided  with  a  sac,  and  the  great  majority  of  those  are  of  congenital  origin. 
The  stomach,  colon,  small  intestines,  liver,  and  even  the  pancreas,  cwcum, 
and  kidney  appear  in  the  protrusion,  and  in  point  of  frequency  in  the  order 
stated.  Stab  aiul  contused  wounds  are  most  often  the  exciting  causes  of 
this  variety  of  hernia,  and  of  those  arising  from  the  former  cause  but  one 


1036  OPERATIVE   SURGERY. 

third  suffer  at  once  from  the  hernial  infliction ;  in  the  remainder,  months 
and  years  may  elajise  before  herniae  become  manifest.  At  all  events,  in  88 
per  cent  of  the  cases  death  follows  sooner  or  later  from  the  effects  of  the 
wound,  prompt  strangulation  covering  about  9,  and  late,  about  14  per  cent 
of  the  deaths.  From  the  aforegoing  it  follows  that  wounds  of  the  diaphragm 
call  for  prompt  explorative  diagnosis  and  repair,  irrespective  of  hernial  mani- 
festation. The  detection  of  a  wound  of  the  diaphragm  is  best  accomplished 
by  manual  examination  made  through  a  high  median  incision  in  the  abdo- 
men. By  this  means  the  under  surface  of  this  muscle  can  be  carefully  and 
comprehensively  examined  on  either  side  of  the  body.  If  a  defect  is  found, 
it  should  be  repaired  as  soon  as  the  condition  of  the  patient  will  permit. 

The  surgical  treatment  of  diaphragmatic  wounds  and  hernia  may  be 
effected  either  by  way  of  the  abdomen  6x  the  chest  (Figs.  1U30,  1031,  and 
1090).  By  the  former  route  the  entrance  is  easy,  but  the  treatment  is  diffi- 
cult because  of  the  position  of  the  diaphragm  and  the  influence  on  the 
protrusion  of  negative  i:)ressure.  The  latter  route,  while  readily  available, 
easy  of  attainment,  and  opposed  to  the  influence  of  negative  pressure, 
exposes  the  pleura  aiul  lung  to  the  consequences  of  thoracic  invasion,  which 
in  feeble  and  diseased  subjects  is  often  a  matter  of  grave  importance.  How- 
ever, as  the  surgeon  in  these  cases  usually  opens  the  abdomen  with  the  view 
of  relieving  intestinal  obstruction,  and  meets,  perhaps,  with  an  unsuspected 
strangulated  diaphragmatic  hernia,  which  has  already  infected  in  a  greater 
or  less  degree  the  pleural  cavity,  and  can  not  be  returned  safely,  if  at  all, 
without  opening  the  jDleural  cavity,  it  is  si;rely  seen  that  the  thoracic  route 
is  often  essential  for  the  treatment  of  such  cases.  A  wound  of  the  diaphragm 
should  be  suspected  when  the  seat,  direction,  and  depth  of  the  injury  are 
such  as  to  suggest  the  possibility,  and  especially  when  the  symptoms  do  not 
conform  with  the  history  of  an  injury  of  a  simpler  nature.  Usually  these 
wounds  are  explored  along  the  line  of  injury,  the  soft  and  hard  parts  being 
turned  aside  as  the  needs  of  observation,  arrest  of  haemorrhage,  and  of  repair 
demand. 

If  the  seat  of  entrance  of  the  penetrating  agent  be  located  at  some  dis- 
tance below  the  ribs,  a  median  abdominal  incision  for  diagnostic  purposes 
may  be  made,  followed  by  a  thoracic,  if  repair  from  below  be  impracticable 
or  a  hernial  protrusion  of  the  diaphragm  be  present.  In  the  pleural  route 
the  recent  wound  or  the  adult  scar  is  employed  as  a  guide  to  the  seat  of 
operation,  A  large  flaji  of  the  soft  parts,  corresponding  preferably  to  the 
seventh  intercostal  space  (Fig.  1090),  is  made,  followed  by  resection  of  two 
ribs  of  sufficient  length  to  afford  the  opportunity  of  careful  observation  and 
of  prompt  adequate  repair  of  the  rupture.  If  a  hernia  be  present,  the 
condition  of  the  protrusion  should  be  carefully  noted  before  reduction  is 
attempted.  If  it  be  gangrenous,  a  commodious  median  abdominal  incision 
should  be  made  at  once,  the  tissues  around  the  point  of  esca])e  thoroughly 
isolated  with  rubber  dam  and  aseptic  gauze  before  an  attempt  at  reduction 
is  made.  And,  too,  the  contents  of  the  intestine,  with  which  it  is  con- 
tinuous, should  be  pushed  aside  and  retained  before  reduction,  not  only  to 
increase  the  opportunity  of    manipulation,  but  also  lessen   the  danger  of 


Ol'MlJA'IMONS   ON    TIIH   'I'lK  >i;AX.  1037 

extravasation.  Wliouovcr  a  lack  of  proper  vital  iiit('<,M-ity  of  tlic  protru- 
sion is  suspocsti'd,  tlu'  linal  tri'atnu'ut  and  ot)st'rvation  should  be  carried 
on  throM,i,di  a  ineilian  ahdoniiiial  incision.  Uesection  of  gungrunous  intes- 
tine and  the  formation  of  artiticial  anus  can  not  be  practiced  through 
tiie  (diest  walls.  When  thoracic  observation  establishes  the  Ixdief  in  ihe 
integrity  of  the  protrusion,  it  should  be  thoroughly  cleansed,  i^turned  to 
the  abdomen,  and  the  0{)ening  in  the  diaphragm  repaired  by  sewing.  The 
wound  of  the  thora.x  is  closeil,  and  the  patient  treated  otherwise  as  for 
liernia  elsewhere. 

The  Precautions. — A  careful  scrutiny  of  ihc  })rotruded  j)art  is  neces.sary 
before  an  attempt  at  reduction  is  made,  especially  if  there  is  reason  to  believe 
that  the  vitality  of  tlic  liernial  ])rotrusion  is  impaired.  Vigorous  traction  in 
reduction  should  not  be  practiced  in  any  instance,  as  relief  can  be  had  if 
only  a  small  incision  into  the  thorax  is  made.  If  air  have  already  entered 
the  thorax,  or  the  opening  be  a  free  one,  or  the  passage  throngh  it  by  the 
side  of  the  neck  of  the  hernia  of  a  small  hollow  instrument  for  admission  of 
air  be  practicable,  the  making  of  the  thoracic  opening  may  be  avoided.  It 
should  be  kej^t  in  mind  that  the  addition  to  the  already  depressed  state  of 
the  patient  of  a  pneumothorax  may  cause  of  itself  a  fatal  issue ;  therefore, 
air  ought  not  to  be  permitted  to  enter  the  pleural  cavity  except  when  a  dis- 
creet use  of  other  methods  of  reduction  has  failed.  The  introduction  of  the 
finger  through  the  opening  by  the  side  of  the  hernia  is  apt  to  injure  the  gut 
at  that  situation,  and  should  not,  therefore,  be  harshly  done.  Instead,  a 
small  grooved  instrument  should  be  introduced  at  the  side,  and  the  opening 
increased  by  cutting,  remembering  always  that  septic  matter  may  at  once 
escape  thro^iigh  the  opening  into  the  abdomen.  Contused  wounds  of  the 
abdomen  and  chest  may  cause  rupture  of  the  diaphragm  with  all  of  its 
manifestations.  The  possibility  of  injury  of  the  pericardium  and  lung 
should  not  be  overlooked. 

The  Remarks. — The  technique  of  rejiair,  of  cleansing,  and  of  drainage 
in  these  cases  is  similar  in  all  important  respects  to  that  of  surgery  of  the 
serous  cavities  generally.  Fatal  issues  quite  too  often  afford  the  opportunity 
for  a  diagnosis  that  at  least  should  have  been  suspected  before.  In  the 
instances  of  aseptic  wounds  the  ribs  may  be  sutured  in  place  by  union  of 
the  denuded  ends  with  line  silver  wire.  The  results  were  considered  already 
in  the  beginning  of  the  discussion. 

Haemothorax. — The  presence  in  the  pleural  cavity  of  a  greater  or  less 
amount  of  Ijlood,  dependent  on  a  wound  of  a  vessel  of  the  thoracic  wall  of 
the  lung,  or  of  an  intrathoracic  viscus  or  vessel,  is  denominated  haemo- 
thorax. The  seat  and  age  of  the  wound,  together  with  the  amount  of 
the  bleeding,  will  indicate  quite  pointedly  the  vessel  or  viscus  involved.  In 
the  great  majority  of  instances  the  bleeding  will  have  ceased  already  when 
the  patient  is  first  visited  by  the  physician,  and  the  primary  aim  shoidd  then 
be  to  maintain  quiet  to  prevent  recurrence  of  the  Invmorrhage.  Later, 
the  question  of  absorption  of  the  blood  will  need  consideration.  Fortu- 
nately, the  strong  tendency  to  ra])id  and  complete  absorption  of  even  large 
amounts  of  blood  from  the  pleural  cavity  without  manifest  local  disturbance 


1038  OPERATIVE   SURGERY. 

favors  the  exercise  of  discreet  waiting  for  the  evidences  of  degenerative 
changes  before  active  steps  are  taken.  When  local  and  constitutional  s^mp- 
toms  indicating  the  presence  of  pus  appear,  the  case  falls  under  the  category 
of  empyema,  and  is  best  treated  by  the  operative  measures  addressed  to  that 
affliction.  If  haemorrhage  recur,  or  be  progressing  at  the  time  of  the  first 
visit,  prompt  measures  for  arrest  must  be  employed  at  once  to  prevent  further 
loss.  If  the  loss  of  blood  arise  from  the  wound  of  a  vessel  of  the  thorax, 
plugging  of  the  wound,  followed  promptly  by  ligature  of  the  bleeding  ends 
under  local  anaesthesia,  should  be  employed.  When,  however,  the  escape 
has  a  deeper  and  more  obscure  origin,  is  persistent  and  dangerous  to  the  life 
of  the  patient  because  of  the  increasing  loss  of  blood,  or  from  its  direct 
interference  with  the  respiratory  capacity,  operative  practice  may  then  be 
regarded  as  the  only  measure  that  will  afford  relief.  Operation  under  these 
circumstances  is  a  serious  matter  indeed,  and  should  always  include  prepara- 
tion for  the  prompt  and  effective  use  of  saline  transfusion. 

Aspiration  of  tlte  tliora.c  may  effect  the  removal  of  a  sufficient  amount  of 
the  blood  to  afford  relief  from  the  respiratory  oppression  without  provoking 
fresh  hasmorrhage.  If  this  simple  measure  fails  to  afford  the  requisite  aid, 
explorative  entrance  of  the  chest  by  raising  an  osteo-cutaneous  flap  of  suit- 
able size,  and  so  located  as  to  provide  the  opportunity  for  free  inspection 
and  proper  repair  of  the  injury,  should  be  practiced  (Fig.  963).  After 
removal  of  the  blood,  the  seat  of  escape  should  be  sought  for  at  once,  and 
the  hfemorrhage  arrested  by  catching  or  clamping  the  bleeding  points  or 
surfaces,  followed  by  suitable  repair  of  the  damaged  structure.  The  bleeding 
points  of  injured  vessels  are  closed  by  ligature.  Injured  viscera  are  treated 
according  to  the  nature  of  the  wound  and  the  length  of  time  safely  at  the 
command  of  the  surgeon.  Small,  shallow  wounds  of  the  lung,  and  those 
demanding  instant  relief,  may  be  satisfactorily  treated  by  the  introduction 
of  iodoform-gauze  plugs,  one  end  remaining  outside  of  the  chest.  But 
in  all  instances  in  Avhich  plugging  is  employed  the  gauze  should  be  car- 
ried to  the  bottom  of  the  wound,  even  though  the  entrance  requires  enlarge- 
ment for  the  purpose ;  otherwise  haemorrhage  will  not  be  fully  arrested. 
Tying  of  the  bleeding  surface  or  opening  witli  a  ligature  has  been  practiced 
successfully,  but  in  the  latter  instance  is  exposed  to  the  risk  of  not  controlling 
entirely  the  divided  structures,  especially  of  the  deeper  parts  of  a  wound. 
The  use  of  continued  or  interrupted  sutures  of  any  form  are  open  to  the 
objections  that  they  invade  the  air  cells,  puncture  the  vascular  structures, 
and  may  fail  to  command  entirely  the  divided  surfaces  of  deep  wounds.  In 
superficial  wounds  sutures  have  been  satisfactorily  employed.  After  repair, 
the  parts  are  thoroughly  cleansed,  drainage  provided,  flaps  restored  to  place, 
and  so  united  as  not  to  interfere  with  drainage,  the  wound  is  dressed  aseptic- 
ally,  patient  placed  on  the  injured  side,  and  quieted  with  small  doses  of 
an  anodyne. 

The  Precautions. — Miscellaneous  probing  of  a  wound  of  the  chest  should 
not  be  practiced.  The  cautious  use  of  a  silver  probe  or  of  a  finger  clothed 
with  a  tight-fitting  aseptic  rubber  cot  (Fig.  IGO)  may  be  of  service  in  determin- 
ing the  direction  of  the  injury  and  the  probability  of  entrance  to  the  chest. 


OPERATIONS   ON    'I'llM    'llloK.W.  ](,;;(j 

in  tlio  absence  ot"  other  si;jfnt-.  Chest  wounds  slioiild  be  jfronipLly  iiiid  asejjtie- 
ally  (•h)si'(l  at  once,  unless  especially  coiitriiindicuted.  After  entrance  to  tlio 
chest,  the  blood  should  be  removed  as  rapidly  as  jiossible  in  order  to  discover 
and  anest  bleeding  at  once.  A  strong  movable  light  will  facilitate  the 
search  for  the  seat  of  injury  and  contribute  much  to  liasten  repair.  Careful 
scrutiny  is  sometimes  requiriMl  to  detect  the  seat  of  a  slight  injury  of  the 
lung,  especially  when  received  at  the  borders  of  that  viscus.  'J'ransfusion 
may  be  required  during  the  course  of  the  o])eration,  ])ossibly  before  and  quite 
certainly  afterward. 

Tlie  Remarks. — Thorough  asepsis  should  be  practiced  in  all  respects. 
The  unusual  tendency  to  fluidity  of  blood  in  the  pleural  cavity  renders  aspira- 
tion for  the  jnirpose  of  removal  entirely  feasible  and  often  iinex])ectedly 
successful.  A  U-shaped  flap  of  the  soft  parts  is  commonly  made  and  turned 
aside  ;  limited  portions  of  two  or  three  ribs  are  then  excised,  often  sub- 
jieriostcally,  and  removed,  followed  by  a  smaller  flap  of  the  pleura  and  inter- 
costal structures.  Injuries  of  tlie  heart  are  treated  under  a  separate  head- 
ing (page  1057).  Tmmobiliz;ation  of  the  chest,  so  far  as  may  be  consistent 
with  the  demands  of  breathing,  and  the  use  of  opium,  to  restrain  coughing, 
are  to  be  commended.  In  those  instances  in  which  much  disorganization  of 
the  lung  is  present,  and  in  which  pressure  is  requisite  to  control  the  bleed- 
ing, sufflcient  gauze  may  be  introduced  into  the  thorax  to  efl'ect  the  purpose. 

77/e  Results. — In  86  cases  of  ha^mothorax  from  penetrating  wounds  of 
the  chest,  23  recovered  and  44  died  without  operation.  Of  the  22  treated 
by  puncture  or  incision  to  relieve  pressure  on  the  lung,  4  died  (Xelaton). 

Abscess  of  the  Lung. — The  history  of  voluntary  surgical  attack  on  the 
lung  is  a  long  one,  replete  with  indications  of  persistent  effort,  interrupted 
by  frequent  discouragement,  and  finally  crowned  with  practical  success. 
Abscesses  vary  in  size,  form,  number,  and  situation — facts  that  should  be 
recognized  as  influencing  the  outcome  of  operative  practice.  Usually  the 
diagnosis  of  abscess  is  established  by  aspiration  before  the  need  of  operation 
is  announced.  Sometimes  the  latter  follows  immediately  the  determination 
of  the  need  by  the  former,  and  is  consequently  a  part  of  the  procedure. 

The  Operation. — Under  thorough  aseptic  preparation  and  local  anges- 
thesia,  introduce  at  the  center  of  the  field  indicating  the  seat  of  the  abscess, 
as  determined  by  the  physical  signs,  a  short,  strong,  aspirating  needle  (Fig. 
101)1)  (with  a  lumen  of  about  half  to  three  quarters  of  a  line  in  diameter) 
already  connected  with  an  aspirator ;  open  the  stopcock  controlling  the  aspi- 
ration as  soon  as  the  end  of  the  needle  is  well  buried  in  the  tissues ;  slowly  and 
cautiously  press  the  end  of  the  needle  into  the  chest,  carefully  watching  at  the 
same  time  for  the  appearance  of  pus  in  the  glass  segment  of  the  tube.  "When 
pus  appears,  leave  the  needle  in  place  as  a  guide  to  the  abscess  if  relief  is  to  be 
souglit  at  once.  Otherwise,  slowly  withdraw  the  needle,  noting  carefully 
the  site,  deviation,  and  depth  of  penetration  for  after  guidance.  Close  the 
seat  of  puncture  with  collodion,  and  while  noting  the  effect  of  the  explora- 
tion prepare  for  operative  relief.  In  operating  raise  a  U-shaped  musculo- 
cutaneous flap  of  ample  dimensions  ;  with  the  convex  portion  posteriorly,  and 
with  tlie  needle  as  a  guide  to  the  i)us,  divide  antero-posteriorly  carefully  along 


1040  OPERATIVE  SURGERY. 

the  course  of  tlie  needle  with  a  scalpel  the  various  tissues  down  to  the  parietal 
pleura,  excising  limited  portions  of  one  or  more  ribs  if  need  be.  //'  the 
pleural  surfaces  are  adherent  to  each  other,  continue  the  dissection  along 
the  needle  into  the  abscess,  which  is  then  carefully  evacuated  and  drained. 
If  adhesions  are  not  present,  and  the  case  is  urgent,  unite  the  pleural  surfaces 
with  each  other  by  sewing  with  chroniicized  catgut  supplemented  with 
gauze  packing,  and  continue  the  dissection.  If  the  case  is  not  urgent,  pack 
the  wound  with  gauze,  and  at  tlie  end  of  two  or  three  days  finish  the  opera- 
tion under  the  protection  of  tlie  newly  formed  adhesions. 

The  Precautions. — The  precautions  incident  to  penetration  of  the  chest 
in  empyema,  etc.  (page  1023  et  seq.),  are  of  equal  force  in  this  condition.  If 
pleural  adhesion  have  not  taken  place,  collapse  of  the  lung  will  follow  inva- 
sion of  the  pleural  cavity,  and  seriously  hinder,  if  not  defeat  entirely,  the  safe 
evacuation  of  the  pus.  Therefore,  one  should  not,  unless  unavoidable,  divide 
the  pleura  until  after  adhesions  are  established.  With  a  non-adherent  pleura 
the  movements  of  the  lung  can  be  seen  and  felt  through  the  exposed  parietal 
layer  of  the  membrane,  and  a  needle  thrust  through  it  into  the  lung  will 
oscillate  with  the  respiratory  movements,  and  not  move  only  upward  and 
downward  with  the  chest  wall  as  in  the  instance  of  pleural  adhesions.  It  is 
often  comparatively  difficult  to  divide  or  pierce  a  thickened  adherent  pleura  ; 
moreover,  the  history  of  the  physical  signs  of  disease  of  the  pleura  will  indi- 
cate adhesion.  Should  pus  escape  into  the  pleural  cavity  during  evacuation 
of  the  abscess,  free  dependent  drainage  of  the  cavity  should  be  established  at 
once,  and  the  cavity  thoroughly  flushed  with  a  saline  solution.  The  fibrous 
bands  often  noted  by  the  finger  in  exploring  abscesses  should  be  cautiously 
treated,  as  they  not  infrequently  support  and  conceal  important  blood-vessels. 
The  introduction  of  the  fingers  into  the  cavities  and  flushing  is  not  advisable. 
In  the  instances  of  non-adhesion,  gauze  pressure  only  is  too  uncertain  to  be 
regarded  as  an  acceptable  substitute  for  sewing  with  catgut.  In  deep  intro- 
duction of  the  exploring  needle,  the  advancing  end  should  be  directed  away 
as  much  as  possible  from  important  structures.  Inasmuch  as  the  abscess  may 
be  missed  entirely  on  exploration,  or  the  pus  be  too  thick  to  flow,  or  have  been 
nearly  discharged  by  coughing,  a  microscopical  examination  of  the  contents 
of  the  lumen  of  the  needle  should  be  made  to  determine  the  nature  of  its 
contents  before  this  means  of  detection  is  discontinued.  Needles  of  in- 
creased caliber  may  be  employed  if  pus  be  found  in  the  lumen  of  the  smaller, 
keeping  in  mind  the  fact  that  it  is  not  always  possible  to  locate  an  abscess 
by  this  method  of  practice.  Abscess  and  empyrmic  cavities  communicating 
with  a  bronchus  should  not  be  flushed,  as  the  fluid  may  enter  the  bronchi 
and  suffocate  the  patient.  Janeway  warns  against  the  danger  of  giving 
anaesthetics  in  such  cases,  and  emphasizes  the  admonition  by  repeated 
instances  within  his  own  knowledge  in  which  patients  have  been  suffocated 
by  pus  while  insensible  to  its  presence  in  the  lung,  because  of  amesthesia. 

The  Remarks. — The  means  for  making  a  passage  through  the  lung  tissue 
into  the  abscess  cavity  are  quite  numerous  and  variously  indorsed  by  opera- 
tors. Trocar  and  cannula,  the  knife,  the  cautery,  and  blunt  dissection  are 
commonly  employed.     Paget  regards  with  especial  favor  the  use  of  a  fine 


Ul'KKATIONS    ON    TIIK    rilUKAX.  ](l41 

director  fitted  closely  jirouiul  the  needle  of  an  exploriiif^  syringe.  'J'liey  are 
caused  to  pierce  the  lung  combinedly,  and  after  deterniiniiij,^  tlie  ])resence  of 
pus  by  aspiration,  the  needle  is  withdrawn,  leaving  the  director  in  j)lace  to 
serve  as  a  guide  to  the  abscess.  Along  the  director  dilating  agents  of  in- 
creasing size  are  successively  carried,  thus  oi)ening  a  commodious  channel 
into  the  abscess.  Cautious  dilatation  is  essential,  otherwise  serious  bleeding 
may  be  ])rovokeil,  requiring  that  the  wound  be  plugged  to  arrest  the  haemor- 
rhage. Cautery  is  a  safe  and  eilicient  agent  when  employed  with  discretion. 
The  advance  through  the  tissue  with  this  agent  should  be  slowly  made  and 
the  instrument  removed  cautiously,  and  only  after  the  tissues  are  seared 
sufficiently  to  permit  the  withdrawal  without  tearing  away  the  cauterized 
tissue  and  causing  severe  haemorrhage.  In  superficial  abscess  blunt  dissec- 
tion may  be  safely  employed.  Hard  pulmonary  tissue  may  be  safely  cut, 
the  soft  as  safely  treated  with  cautery.  The  cautery  and  gauze  tampons 
should  always  be  at  hand  to  arrest  haemorrhage.  Cavities  at  the  apex  of  the 
lung  drain  readily  into  a  bronchus  ;  those  at  the  base  do  not,  and  for  a])par- 
ent  reasons. 

The  distance  of  the  proposed  entrance  of  the  needle  should  be  indicated 
ujion  it  before  beginning  the  act,  to  avoid  needlessly  dangerous  encroachment 
on  the  contents  of  the  thorax.  The  sewing  together  of  the  pleural  mem- 
branes in  the  absence  of  adhesion  lessens  the  danger  of  collapse  of  the  lung, 
and  correspondingly  facilitates  the  ease  and  rapidity  of  subsequent  operative 
efforts.  Tiiffier  commends  transpleural  examination  of  the  lung  for  locali- 
zation of  abscess.  The  parietal  pleura  is  separated  from  the  chest  wall  for  a 
sufficient  extent  to  meet  the  required  purpose,  and  through  it  the  physical 
state  of  the  lung  is  estimated  by  the  hand,  and  thus  the  abscess  is  located. 
However,  this  additional  severity  to  the  operation  added  to  the  increased 
opportunity  of  infection,  does  not  favorably  commend  this  modification.  If 
an  abscess  communicate  with  a  bronchus,  a  tampon  of  gauze  should  be  em- 
ployed to  close  the  opening  into  the  bronchus,  and  thus  aid  the  function  of 
respiration,  otherwise  a  drainage  tube  may  be  employed.  Beck  introduces  a 
narrow  strip  of  gauze  into  the  abscess  cavity,  cleanses  the  pleural  cavity,  packs 
it  with  gauze,  and  administers  morphin  to  control  the  cough.  He  causes 
expulsion  of  the  pus  from  the  cavity  by  causing  the  patient  to  blow  out 
from  time  to  time  with  the  mouth  and  nose  closed. 

The  Results. — Paget  reports  14  complete  recoveries  in  42  operations  for 
simple  abscess;  3  recovered  with  fistula,  24  died,  and  in  1  the  result  is  un- 
known. Fabricant  reports  38  cases  of  operation  for  abscess,  with  29  cures. 
Taufcvt  reports  5  operations  for  abscess— all  successful.  Eechis  reports  1 7 
operations  for  abscess  following  fibrinous  pneumonia,  with  14  cures  and  3 
deaths. 

Bronchiectasis. — Operations  on  dilated  bronchi  are  very  unsatisfactory. 
(The  majority  of  patients  do  not  improve  at  all,  and  the  few  that  do  as  a 
rule  rapidly  become  worse.)  While  a  single  well-formed  cavity  may  be 
amenable  to  operation,  the  fact  that  there  are  usually  multiple  dilatations, 
and  at  the  best  but  temporary  benefit  need  be  expected,  offers  a  meager 
benefit  for  the  dauorer  incurred.     The  means  of  detection  of  the  cavity  and 


1042  OPERATIVE   SURGERY. 

the  general  technique  of  the  operative  procedure  are  substantially  similar  to 
those  employed  for  abscess  of  the  lung. 

The  Results. — In  hronchiectasis,  'riifjier  reports  45  operations  with  but  7 
improvements;  Paget  reports  12  o2)erations,  with  8  deaths  and  no  complete 
recoveries. 

Gangrene  of  the  Lung. — Gangrene  of  the  lung  is  a  secondary  disease,  and 
therefore  largely  inlluenced  in  extent,  location,  and  circumscribed  state  by 
the  nature  of  the  disease  or  injury  which  it  complicates.  Therefore,  it  is 
important  in  considering  the  advisability  of  surgical  effort  to  note  whether 
or  not  the  associated  cause  leads  to  the  circumscribed  or  diffuse  variety  of 
gangrene,  and  whether  it  is  likely  to  be  superficial  or  deep.  Uncircum- 
scribed  or  diffuse  gangrene  of  the  lung 'is  much  less  suited  for  opera- 
tion than  that  located  in  less  delicate  and  important  functional  parts  of 
the  body.  And  in  the  lung  or  elsewhere  in  the  body,  circumscribed  super- 
ficial gangrene  is  the  most  favorable  for  operative  treatment.  Operation 
should  be  performed  early  enough,  if  possible,  to  anticipate  the  occurrence 
of  sepsis,  perforation  of  the  pleura,  and  consequent  pyaemia  and  ha?morrhage. 

The  Operation. — The  advantages  of  physical  diagnosis  and  of  explora- 
tive puncture  are  utilized  to  locate  the  seat  of  the  disease.  Turn  aside  a 
U-shaped  musculo-cutaneous  flap  corresponding  to  the  site  of  the  suspected 
gangrene  ;  cautiously  resect  a  portion  of  one  or  more  ribs  carefully,  avoiding 
injury  of  the  pleura.  If  adhesions  are  not  present.,  so})arate  the  parietal 
pleura  from  the  chest  wall  and  practice  transpleural  palpation  of  the  lung, 
in  order  to  locate  accurately  by  touch  the  seat  of  the  disease.  Having  located 
the  seat  of  the  disease,  resect  the  ribs  sufficiently  to  permit  of  easy  approach 
to  and  treatment  of  the  gangrene  ;  sew  together  around  the  superficial  area 
of  disease  by  means  of  a  continuous  chromicized  catgut  suture,  introduced 
in  the  manner  of  the  domestic  "  back-stitch "  (Roux),  the  non-adherent 
pleural  surfaces ;  pack  the  outer  limits  of  the  wound  with  gauze,  and  intro- 
duce at  the  center  of  the  area  an  aspiration  needle  ;  cut  through  the  parietal 
pleura  freely,  thus  exposing  the  seat  of  the  disease  ;  open  into  the  gangre- 
nous area  with  a  trocar  and  cannula,  or  with  a  cautery  ;  cut  away  with  knife 
or  scissors  the  superficial  gangrenous  portions,  wiping  the  parts  with  gauze 
pads.  If  fluid  be  present  in  the  pleural  cavity  it  should  be  removed,  tlie 
cavity  thoroughly  cleansed,  drained,  and  packed  with  gauze  before  the  gan- 
grene is  treated.  If  ample  adhesions  be  present  between  the  serous  surfaces 
there  is  no  need  for  delay  in  the  operation. 

The  Precautions. — It  is  wise  to  pack  the  wound  after  sewing  together 
the  pleural  surfaces,  and  wait  four  or  five  days  before  attacking  the  gangre- 
nous area,  if  the  patient's  condition  will  warrant  the  delay.  An  infected 
pleural  cavity  should  be  kept  thoroughly  cleansed,  and  dependent  drainage 
should  be  maintained  and  gauze  packing  employed  during  the  treatment  of 
a  gangrenous  lung.  Gangrene  extends  downward  toward  the  base  of  the 
lung  ;  therefore  the  opening  into  the  chest  should  be  extended  in  a  downward 
direction  for  the  purposes  of  treatment.  The  j)leura  is  attached  less  firmly 
to  the  intercostal  structures  than  to  the  borders  of  the  ribs  ;  consequently 
the  separation  should  be  commenced  at  the  former  situation.     In  separating 


OPERATIONS   ON   THE    I'lloltAX.  1043 

tlie  pleura  from  the  chest  wall  cure  shoiilil  be  exercised  to  prevent  tearing  ; 
the  separation  should  be  done  slowly  with  the  fingers  toward  the  pleura 
(Tuftier).  In  sewing  the  pleural  surfaces  together  the  visceral  layer  should 
be  pickeil  up  during  ins})initi()ii,  and  in  order  to  secure  a  reliable  line  of 
a()position  the  continuous  suture,  preferably  the  "  back-stitch  "  variety, 
should  be  introduced.  When  gangrene  is  deeply  situated  in  the  lung,  the 
cautery  at  a  dull-red  heat  is  the  safer  agent  to  employ  in  the  treatment. 

Tlie  Eonitrks. — Prompt  operation,  if  iiracticable,  should  follow  the  with- 
drawal of  pus  from  a  lung  cavity,  by  aspiration  in  the  absence  of  adhesions 
at  the  seat  of  puncture,  to  avoid  infection  of  the  pleural  cavity.  Not  infre- 
quently cases  treated  by  simple  })uncture  of  the  cavity  through  the  chest 
wall  with  trocar  and  cannula,  followed  by  drainage,  the  tube  being  intro- 
duced through  the  latter  agent,  have  satisfactorily  recovered.  Pleural  ad- 
hesion should  have  preceded  the  employment  of  the  measure.  Counter 
drainage  of  a  cavity  in  the  lung  may  be  deemed  advisable.  Incisions  for 
gangrene,  as  incisions  for  abscess  that  fail  to  locate  the  disease,  are  not  neces- 
sarily fruitless,  since  not  infrequently  in  a  few  days  a  free  discharge  takes 
place  through  the  incision  and  cure  quite  promptly  follows.  Gangrenous 
and  abscess  cavities  should  be  wiped  out  and  not  flushed,  especially  when 
the  cavity  communicates  with  a  bronchus  or  exposes  the  pleural  cavity  to 
the  danger  of  infection.  The  X  rays  aid  in  determining  the  location  of 
abscess  and  gangrene  of  the  lung. 

The  Results. — In  gangrene  of  the  hing  without  operation,  75  per  cent  of- 
the  cases  die  (Reclus).  iSo7ineiiberg  reiports  47  operations  with  35  recoveries. 
Fahricant  reports  26  operations,  with  16  cures  and  10  deaths.  Taiifert 
reports  10  operations,  with  7  cures  and  3  deaths.  Rectus  reports  13  cases, 
with  11  cures  and  i  deaths. 

Tumor  of  the  Lung. — According  to  Tuffier,  a  patient  with  primary  malig- 
nant tumor  of  the  lung  has  never  been  subjected  to  operation.  However, 
secondarv  sarcomata  have  been  successfully  removed.  AVe  can  not  favor 
this  practice,  because  notliing  tangible  can  be  offered  to  those  suffering  from 
secondary  manifestations  commensurate  with  the  dangers  and  discomfort  at- 
tendant on  operations  for  their  removal  at  this  situation.  In  the  instance 
of  hydatid  growths  the  conditions  are  different.  The  lungs  and  pleura  suffer 
next  in  frequency  to  the  liver  from  hydatid  disease. 

The  Oj^ration.—^wxictwre  and  incision  are  the  surgical  methods  of  prac- 
tice that  will  be  considered,  and  the  former  is  mentioned  for  the  purpose  of 
condemnation  rather  than  encouragement.  Puncture  even  with  a  small 
needle  for  diagnostic  purposes  should  be  promptly  followed  by  incision,  to 
anticipate  fatal  pleural  inflammation  from  leakage,  and  often  lung  compli- 
cations of  even  a  prompter  and  more  fatal  outcome. 

Tlie  technique  of  operation  by  incision  is  not  dissimilar  in  principle  to  that 
employed  In  like  treatment  of  hydatid  growths  connected  with  serous  mem- 
branes elsewhere  in  the  body.  The  tumor  is  located  by  the  physical  signs,  and 
perhaps  identitied  by  means  of  a  small  hypodermic  needle.  A  flap  is  raised 
and  turned  aside  and  a  portion  of  one  or  more  of  the  ribs  resected,  followed 
by  exposure  of  a  limited  area  of  the  parietal  pleural.     If  the  pleural  surfaces 


1044  OPERATIVE  SURGERY. 

are  adherent  to  each  other,  the  operation  is  continued  ;  if  not,  the  wound  is 
stuffed  with  gauze  for  four  or  five  days,  in  order  to  establish  adhesions. 
When  adhesions  are  formed  over  a  sufficient  area  to  afford  proper  protection 
to  the  pleural  cavity  from  hydatid  infection,  the  tumor  is  opened  along  the 
course  of  an  exploring  needle  by  means  of  cautery  or  incision.  The  contents 
of  the  cavity  are  evacuated  without  the  aid  of  irrigation  or  curetting.  A 
short,  soft,  rubber  drainage  tube  of  large  calibre  is  introduced  into  the  cavity 
and  the  wound  dressed  with  an  abundance  of  gauze. 

Tlie  Precautions. — Care  should  be  exercised  to  cause  a  wide  enough  area 
of  adhesion  to  prevent  the  entrance  into  the  pleural  cavity  of  infecting 
agents.  The  union  of  the  pleural  surfaces  by  sewing  should  not  be  relied 
upon  to  the  exclusion  of  packing,  from  fear  of  leakage ;  full  reliance  can  be 
placed  on  the  packing  for  adhesion  purposes.  Preparation  for  prompt  ex- 
amination of  the  fluid  withdrawn  by  the  needle  and  for  operative  action 
should  have  been  made  before  the  needle  is  inserted,  in  order  that  incision 
may  at  once  follow  the  diagnosis  of  hydatid  disease.  Irrigation  and  curett- 
ing of  the  cavity  should  not  be  practiced,  because  of  the  great  danger  of 
invasion  of  the  bronchial  tubes.  The  major  part  of  the  contents  of  the 
cyst  may  be  cautiously  removed  by  the  finger  or  a  small  spoon,  the 
remainder  escaping  with  the  subsequent  discharges. 

Tlie  Eemarks. — The  cough  that  often  attends  is  lessened  by  anodynes. 
Symptomatic  and  other  complications  are  treated  as  they  arise. 

The  Results. — Paget  regards  the  death  rate  as  being  from  50  to  60  per 
cent  without  surgical  treatment,  and  states  that  the  suffering  of  those  who 
recover  is  severe  and  prolonged.  The  death  rate  from  puncture  is  variously 
estimated,  being  from  69  (Maydl)  to  27  (Thomas)  per  cent.  The  death  rate 
from  incision  is  estimated  to  be  from  16  (Thomas)  to  20  (Lopez)  per  cent. 

Tuberculosis  of  the  Lungs. — Active  surgical  interference  in  pulmonary 
tuberculosis  has  been  quite  extensively  practiced  and  widely  discussed  at 
various  times ;  and  although  striking  instances  of  relief  are  not  infrequently 
reported,  the  proposition  itself  has  not  met  with  extended  professional 
approval.  The  reasons  for  this  fact  are  so  apparent  as  not  to  require  con- 
sideration at  this  time. 

Tubercular  Cavities. — In  not  a  few  instances  has  the  incision  of  tuber- 
cular cavities  been  followed  by  temporary  relief,  but  rarely  indeed  by  final 
cure.  The  fact  that  only  palliation  Avas  expected  seems  to  justify  further 
effort  in  this  regard,  unless  it  shall  appear  that  success  is  attained  at  a  too 
great  sacrifice.  The  localization  of  the  incision  in  the  treatment  of  these 
cavities  is  indicated  by  the  physical  signs.  The  exposure  of  the  parietal 
pleura  is  accomplished  in  the  same  way  and  is  guided  by  the  same  reasons  as 
for  abscess,  etc.  In  these  cases  the  pleural  surfaces  are,  in  a  great  majority 
of  the  cases,  already  adherent,  consequently  the  operator  proceeds  at  once  to 
invade  the  cavity  by  means  of  a  trocar  and  cannula  or  with  cautery.  The  first 
two  agents  are  employed  more  frequently  in  this  than  in  the  previously  con- 
sidered conditions.  However,  if  haBmorrhage  is  feared  because  of  the  great 
depth  of  the  cavity  beneath  the  surface  of  the  lung,  or  for  any  other  reason, 
cautery  is  still  the  preferable  agent  for  use.     After  the  opening  is  estab- 


OPERATIONS   (»\    TIIK   TII(»I{AX.  ^945 

lislied  luul  the  coiiLciily  are  cvacuiitt'cl,  cleansing  (jf  the  cavity  l)v  wiping  or 
spraying  with  sootliing  aseptic  medicated  Hnids  is  indicated.  'I'he  removal 
of  the  deleterions  mjitter  from  the  cavity  is  commonly  pi-omptly  followed  bv 
a  subsidence  of  the  constitutional  symptoms  and  an  abatement  of  the  local 
suffering  and  annoyance.  As  the  result  of  these  changes,  the  general  condi- 
tion of  the  patient  improves  for  a  longer  or  shorter  period,  wlien  finally  the 
advance  of  the  disease  in  other  parts  of  the  lungs,  or  the  increase  in  the 
gravity  of  the  complications  already  established,  weaken  the  patient  and 
finally  cause  death.  If  the  patient  is  so  fortunate  as  to  be  inflicted  with 
but  a  single  cavity  or  the  tendency  of  the  disease  be  toward  recovery,  he 
secures  a  prolonged  respite  and  perhaps  a  final  cure,  or  possibly  it  may  be 
said  that  he  recovers  sooner  and  with  less  suffering  because  of  the  operation. 

The  Precautions. — Great  care  should  be  taken  to  prevent  the  entrance 
of  air  into  the  pleural  cavity,  for  the  reason  that  tlie  addition  of  the  effects 
of  a  pneumothorax  to  that  of  the  already  crippled  state  of  the  lungs  might 
seriously  complicate  matters,  if  not  become  the  cause  of  speedier  death. 
Careless  manipulation  of  the  walls  of  a  cavity  may  cause  troublesome  haem- 
orrhage, and  irrigation  distressing  cough,  and  sufTocating  sensations.  A  cir- 
cumscribed pneumothorax  may  be  mistaken  for  a  tuberculous  cavity.  The 
opening  in  the  chest  wall  should  be  so  extended  as  to  secure  good  drainage. 

The  Remarks. — The  X  rays  may  aid  in  the  diagnosis  of  tlie  location  of  a 
tuberculous  cavity.  The  employment  of  antiseptic  solutions  in  the  treat- 
ment of  these  cavities  has  not  proved  satisfactory.  The  use  of  a  solution  of 
tuberculin  for  this  purpose  has  been  extolled,  but  with  questionable  judg- 
ment. Sometimes  contiguous  tuberculous  collections  empty  into  the  primary 
cavity.  A  failure  to  find  an  accumulation  of  tuberculous  products  may  be 
followed  soon  by  their  escape  through  the  pulmonary  incision. 

The  BesuUs. — Little  can  be  said  of  favorable  results.  It  is  estimated 
that  of  100  cases  operated  on  5  die  from  the  operation,  70  live  only  two 
weeks  afterward,  and  15  less  than  four.  Paget  reports  8  cases  with  6  better- 
ments and  2  deaths. 

Resection  of  a  Tuberculous  Deposit  in  the  Lung. — The  removal  of  a 
part  or  the  whole  of  the  apex  of  the  lung  for  the  purpose  of  cure  of  tuber- 
culosis is  not  a  practical  proposition,  as  the  limits  of  the  disease  can  not  yet 
be  established.  The  area  of  operative  approach  is  small,  being  bounded 
above  by  the  clavicle,  below  by  the  second  rib,  and  laterally  by  the  sternum 
and  pectoralis  minor  (Fowler).  The  opening  is  made  in  front  through  a  U 
or  H-shaped  incision.  The  importance  of  the  clavicle  and  the  first  rib 
require  that  their  sacrifice  be  not  made  in  the  furtherance  of  a  so  unrequit- 
ing  and  meaijer  return.  The  second  and  third  ribs  are  therefore  resected 
if  need  be. 

Titjfier  exposed  the  parietal  pleura  through  the  second  intercostal  space, 
and  without  resection  of  a  rib  established  an  extrapleural  pneumothorax  by 
separating  the  pleura  from  the  chest  wall,  gaining  at  the  same  time  the 
opportunity  of  locating  the  pulmonary  induration  by  means  of  transpleural 
palpation.  He  opened  the  pleura,  grasped  with  forceps  the  indurated  por- 
tion, dragged  it  through  the  intercostal  space,  removed  the  tubercular  mass, 


1046  OPERATIVE   SURGERY. 

returned  the  lung  to  the  chest,  dressed  the  wound  without  drainage,  and  the 
patient  made  a  prompt  recovery. 

The  Comments. — The  production  of  an  extrapleural  pneumothorax 
presses  together  the  pleural  surfaces,  preventing  the  entrance  of  air  into  the 
pleural  cavity.  The  suturing  together  of  the  respective  layers  more  rarely 
accomplishes  the  purpose.  The  portion  of  tissue  removed  is  transfixed  at 
the  bone  and  securely  ligatured,  the  diseased  portion  is  cut  away,  the  lung 
returned  to  the  chest,  and  the  wound  treated  without  drainage. 

Tlie  Bes2iUs. — Paget  reports  5  operations  with  1  complete  recovery  and 
•4  deaths.  Reclus  asserts  that  "  resection  of  a  tuberculous  focus  ought  to  be 
proscribed." 

Temporary  pneumothorax  for  the  cure  of  pulmonary  tuberculosis,  sug- 
gested bv  an  Italian  surgeon  some  years  ago,  has  been  lately  presented  to  the 
profession  in  an  interesting  and  able  manner  by  Murphy,*  of  Chicago.  The 
pneumothorax  is  caused  by  injecting  nitrogen  gas  into  the  pleural  cavity 
of  the  diseased  lung,  thus  imitating  Nature's  efforts  at  cure  by  placing 
the  lung  in  correspondingly  similar  conditions.  The  gas  is  introduced 
by  means  of  a  needle  governed  by  a  stopcock,  without  especial  pain  or 
unfavorable  symptoms.  The  gas  will  remain  for  months  unabsorbed  in 
the  thorax  and  the  introduction  can  be  repeated  when  required.  Murphy 
regards  the  introduction  of  the  gas  into  a  vein  as  the  chief  risk  attending 
the  use,  and  reports  strikingly  suggestive  results  following  the  plan  of  treat- 
ment under  his  own  observation.  The  writer  commends  the  study  of  Dr. 
Murphy's  able  paper  on  the  subject  while  suspending  judgment  and  awaiting 
more  conclusive  proofs  of  the  virtues  of  the  practice. 

Mediastinal  Thoracotomy. — The  thorax  can  be  opened  in  front  or  behind 
for  the  purpose  of  removal  of  obstruction  in  the  oesophagus  or  bronchi,  and 
for  the  relief  of  morbid  processes  in  the  mediastina.  The  intricate  ana- 
tomical relations  and  the  difficulty  of  proper  treatment  afterward  render  the 
adoption  of  the  anterior  route  for  the  removal  of  bronchial  and  oesophageal 
obstructions  well-nigh  impracticable.  Posterior  thoracotomy  is  well  suited 
for  the  requirements  of  drainage,  and  presents  less  complicated  anatomical 
problems  for  solution.  A  knowledge  of  the  anatomical  features  of  the 
operation  can  be  gained  from  text-books  on  anatomy.  XaHloff  in  1888, 
followed  by  Potarca  and  by  Qiiena  and  Hartmann,  directed  attention  to 
opening  the  chest  posteriorly,  mainly  for  the  purpose  of  reaching  the 
oesophagus  and  bronchi  in  cases  of  persistent  obstruction.  Rushmore, 
in  his  somewhat  recent  striking  case  of  bronchial  obstruction,  deter- 
mined to  open  the  chest  in  front,  but  was  obliged  to  desist  early  in  the 
course  of  the  attempt  because  of  the  alarming  state  of  the  patient.  Eush- 
more  has  since  given  preference  to  the  posterior  method  of  practice  in  these 
cases. 

The  writer  in  1895  presented  to  the  American  Surgical  Association  a 
paper  on  this  subject,  from  which  the  following  extracts  bearing  on  the 
technique  of  the  operation  are  substantially  taken. 

*  Journal  of  the  American  Medical  Association,  July  2.3d,  30th,  and  August  6th,  1898. 


ol'llUA  TldNS   ()X    'I'lll';    'i'llolLW.  1(),]7 

The  Position  of  the  Patient. —  Tliu  i)utient  should  be  placed  obliquely  on 
the  abdoiueu,  with  the  shoulders  so  supported  as  to  cause  the  least  possible 
interference  with  resj)iratory  movements  of  the  thorax.  The  side  to  be 
attacked  should  be  upj)ermost,  and  the  body  securely  fixed  in  this  position, 
in  order  that  no  disturbance  of  it  shall  interfere  with  the  line  of  vision,  nor 
lead  to  a  misdirection  of  the  manipulative  methods  employed  for  the  purpose 
of  relief.  The  seu})ula  should  be  drawn  forward  out  of  the  way.  Each 
assistant  should  be  at  his  post,  aiul  have  received  careful  instructions  regard- 
ing his  duty. 

The  Ascertdinment  of  the  Proper  Seat  of  the  Obstruction. — This  step  is 
a  very  important  one,  and  should  be  determined  with  great  care  and  delib- 
eration since  the  proper  location  is  essential  to  a  good  view  of  the  deep 
parts  of  the  wound,  and  to  the  precise  and  delicate  steps  of  the  most  impor- 
tant part  of  the  technique.  The  center  of  the  field  of  operation  should,  if 
practicable,  correspond  to  the  seat  of  obstruction  or  disease,  for  obvious 
reasons.  If  the  obstruction  be  in  the  oesophagus,  and  of  sufficient  density 
when  2)ercussed  by  a  metallic  instrument  to  produce  sound,  a  stethoscope 
applied  to  the  back,  especially  to  the  right  side,  will  define  the  situation  by 
fixing  the  point  of  greatest  density.  Also  the  comparative  relation  of  the 
obstruction  to  an  individual  vertebra  may  be  estimated  by  ascertaining  by 
means  of  a  graduated  bougie  its  distance  from  the  upper  incisor  teeth.  This 
comparative  relation,  and  possibly  the  nature  of  the  obstruction,  can  be 
established  by  means  of  radiography.  Having  determined  numerically  the 
body  of  the  vertebra  contiguous  to  the  obstruction,  the  tip  of  the  spinous 
process  of  this  vertebra  and  the  one  above  should  be  carefully  located.  It 
will  be  noticed  that  as  a  rule  the  tip  of  the  spinous  process  of  a  vertebra  is 
opposite  to  the  rib  of  the  next  vertebra  below,  and  therefore  the  tip  of  a 
spinous  process  will  indicate  quite  correctly  the  rib  nearest  the  center  of  the 
field  of  operation. 

The  Shape  and  Size  of  the  Flap. — A  flap  about  three  inches  square, 
including  the  tissues  down  to  the  ribs,  when  reflected  inward,  afii'ords  amjile 
sjiace  for  work  and  observation.  It  should  correspond  to  three  I'ibs,  the 
middle  one  of  which  should  be  the  center  of  the  operation  field.  The  par- 
allel incisions  should  be  made  carefully,  otherwise  the  knife  may  pass  between 
the  ribs  and  enter  the  pleural  cavity. 

Tite  Treatment  of  the  Ribs. — Portions  of  not  less  than  three  ribs  should 
be  displaced  from  the  angles  to  the  outer  extremities  of  the  transverse  pro- 
cesses, in  order  to  gain  proper  room  for  observation  (Fig.  1261).  The  middle 
one  of  the  three  should  be  cautiously  divested  of  the  soft  parts  on  the  exter- 
nal surface  and  the  borders  by  means  of  a  sharp  periosteotome,  carefully 
avoiding  the  parietal  pleura.  The  pleura  is  then  separated  from  the  inner 
surface  of  the  rib  by  means  of  a  strong  antiseptic  silk  ligature  carried 
beneatli  it  by  an  aneurism  needle  and  moved  to  and  fro  until  the  rib  is  free 
the  entire  width  of  the  wound.  A  Gigli-IIaertel  saw  is  then  drawn  into 
position  by  the  ligature,  and  the  rib  is  divided  at  the  limits  of  exposure  and 
removed. 

The  pleura  is  then  cautiously  separated  from  the  inner  surfaces  of  the 


1048 


OPERATIVE  SURGERY. 


intercostal  tissues  and  the  ribs  immediately  above  and  below  the  opening. 
The  fingers  should  be  used  for  tliis  purpose,  and  the  separation  made  only 
during  expiration.     Attention  is  next  directed  to  increasing  the  size  of  the 


Fig.  1261. — The  operation  of  posterior  thoracotomy,  the  author's  method, 
cate  the  three  ribs  involved  in  this  illustration. 


a,  b,  c  indi- 


thoracic  wound  by  the  displacement  of  a  similar  portion  of  the  adjacent 
ribs.  The  intercostal  vessels  between  these  ribs  are  tied  at  the  outer  and 
inner  limits  of  the  wound.  The  ribs  are  then  divided  in  the  same  manner 
as  the  first,  carefully  maintaining  the  nutritive  integrity  of  the  intercostal 
tissues  at  the  outer  borders  of  the  fragments.  The  fragments  are  then 
turned  outward,  while  hinged  as  it  were  to  the  contiguous  ribs  by  the  inter- 
vening intercostal  structures,  in  which  intercostal  vessels  pass  undisturbed. 
(Fig.  1262).  This  method  of  treatment  of  the  ribs  secures  for  the  fragments 
the  best  possible  nutritive  advantages  when  returned  and  fastened  in  posi- 
tion, and  also  it  reduces  to  a  minimum  the  danger  of  laceration  of  the  pleura 
by  the  bony  extremities. 

The  Prevention  of  Hmmorrhage. — Prompt  ligature  of  all  bleeding  points, 
and  careful  manipulation  in  the  approach  to  the  obstruction,  offer  the  meas- 
ures best  intended  to  prevent  tlie  occurrence  of  haemorrhage. 

The  Location  of  the  Obstruction. — The  site  of  the  obstruction  in  the 
oesophagus  is  easily  made  out  by  the  combined  aid  of  the  finger  in  the  wound 
and  a  bulbous  bougie  in  that  passage.  If  the  pleura  be  gently  pushed  out- 
ward with  the  fingers,  the  movements  of  tliC  bougie  in  the  oesophagus  can 
be  easily  seen  at  the  right  side  in  the  greater  part  of  the  cavity.  A  strong 
electric  light  is  a  very  important  aid  at  this  time.  If  the  obstruction  be  in 
a  bronchus,  this  tube  can  be  easily  located  by  the  finger  before  it  is  exposed 


OrEKA'riUNS   UN    TllK    JUoIlAX. 


1U4'J 


to  view.  Tlie  clmracteristic  incomplotc  rings  of  the  bronchus  are  readily 
felt  as  they  lie  directly  forward  and  about  an  inch  and  a  half  from  the 
opening  into  the  chest. 

The  Avoidance  of  Important  Stractures. — This  desideratum  relates  not 
only  to  approaching  the  situation  of  the  obstruction,  but  also  to  the  passage 
containing  it.  The  vena  azygos,  the  aorta,  the  pulmonary  vessels,  and  the 
pneumogastric  nerves  must  be  cautiously  treated. 

The  Removal  of  the  Obstruction. — If  the  obstruction  be  in  the  asophagus 
or  a  broiiclius,  the  incision  for  removal  should  be  made  in  tlie  long  axis  of 
the  tube,  and  of  sutKcient  length  to  permit  the  withdrawal  without  lacera- 
tion of  the  structures.  Long-handled  instruments  with  short  blades  and 
biting  surfaces  are  essential,  not  only  on  account  of  the  depth  of  the  wound, 
but  for  the  purpose  of  economizing  space  and  jiermitting  the  entrance  of 
light. 

The  Treatment  of  the  Incised  Tube. — The  tube  should  not  be  closed 
since  the  presence  of  mucous  and  inflammatory  products  that  rapidly  super- 
vene as  the  result  of  the  obstruction,  to  say  nothing  of  the  similar  products 
arising  from  the  manipulative  procedure  itself,  will  prevent  union.  An 
iodoform  tamponade  supplemented  with  a  centrally  located  drainage  tube 
will  meet  the  indications. 

Tlie  Beplacement  of  the  Fragments. — The  central  rib  fragment  is  not 
replaced,  but  the  upper  and  lower  fragments  are,  being  fastened  in  position 


Fig.  1262. — The  operation  of  posterior  thoracotomy,  author's  uietliod.     Middle  rib  re- 
moved, the  upper  and  lower  ones  turned  aside,  exposing  the  jileura  and  bronchus. 

by  means  of  silkworm  gut  or  fine  silver  wire.  If  a  proper  aseptic  state  of  the 
parts  can  be  maintained,  the  bone  fragments  will  be  nourished  sufficiently 
by  the  vascular  hingelike  attachments  to  the  adjacent  ribs  to  secure  union. 

The  Adjustment  of  tlie  Flap  and  Dressing  of  the  E.dernal  Wound. — The 
former  step  must  be  carefully  considered,  as  the  flap  can  not  be  accurately 


1050  OPERATIVE   SURGERY. 

adjusted  at  the  outset  on  account  of  the  presence  of  the  drainage  agents 
described.  The  major  dressings  in  ordinary  use  for  aseptic  results  will 
suffice  in  this  instance. 

Tlie  Precautions. — The  utilization  of  a  good  light,  the  control  of  bleed- 
ing, the  avoidance  of  laceration  of  the  pleura  and  prompt  closure  of  the 
opening,  the  cautious  approach  to  the  point  of  obstruction,  the  careful 
oijservation  of  the  patient's  condition  and  prompt  treatment  of  bad  symptoms, 
and  the  arrest  of  the  operation  when  demanded,  should  characterize  the 
procedure. 

The  Remarks. — The  operation  bespeaks  urgent  requirement  and  grave 
consideration,  coupled  with  consummate  care  and  forethought.  It  should  not 
be  attempted  until  other  means  of  relief  are  tried  and  have  failed  ;  nor 
should  delay  in  tlie  attem])t  have  sacrificed  already  the  strength  and  courage 
of  the  patient.  Aseptic  methods,  great  caution,  and  the  ability  to  scrutinize 
the  steps  of  the  procedure  are  the  technical  guides  to  safety  and  success. 
The  advantages  of  the  posterior  over  the  anterior  incision  for  the  purpose  of 
exposing  the  bronchi,  the  oesophagus,  and  mediastinal  growths  are  too 
obvious  almost  to  require  mention.  For  the  complex  anatomical  relations 
of  the  anterior  way  are  substituted  the  much  simpler  ones  posterior.  The 
great  desideratum  of  all  wounds,  and  especially  those  of  septic  associations, 
is  good  dependent  drainage.  And  if  for  no  other  reason  than  this  the  pos- 
terior way  possesses  an  advantage  which  the  anterior  can  not  offset  whatever 
else  may  be  said  in  its  favor.  If  the  pleura  be  torn,  the  opening  should  be 
closed  at  once  by  tying  or  stitching  with  fine  silk. 

The  seat  of  pressure  on  the  tesophagus  from  without  can  be  located  in 
the  same  manner  as  that  employed  when  the  lumen  is  obstructed  from 
within.  While  non-malignant  involvement  of  the  posterior  mediastinum  is 
amenable  to  surgical  treatment,  the  expectation  of  adding  comfort  or 
longevity  in  malignant  infliction  at  this  situation,  by  surgical  means,  is 
doubtful.  In  cases  of  an  assured  location  of  a  foreign  body  deeply  situated 
in  a  bronchus,  Tare  suggests  that  the  approach  to  the  obstruction  be  made 
through  the  lung  tissue  by  means  of  actual  cautery. 

Curtis.,  in  1896,  performed  posterior  thoracotomy  for  the  relief  of  ob- 
struction of  a  bronchus  of  four  or  five  days'  standing  in  a  boy  about  eleven 
years  old.  Because  of  the  pioneer  nature  of  the  operation  on  the  living 
patient,  and  the  established  reputation  of  the  surgeon,  the  full  details  of 
the  operation  are  quoted  : 

"  The  OjJeration. — Chloroform  anaesthesia.  The  patient  was  turned  over 
upon  his  face,  one  shoulder  resting  upon  a  sandbag,  so  as  to  render  respira- 
tion easier.  A  quadrangular  flap  was  raised  from  the  posterior  surface  of  the 
chest,  with  its  base  outward  at  the  scapula  and  its  free  edge  near  the  vertebral 
spines  of  the  fourth,  fifth,  and  sixth  dorsal  vertebra^.  (The  tips  of  the 
dorsal  spines  are  on  the  same  level  as  the  angles  of  the  ribs  attached  to  the 
corresponding  vertebroe.)  This  flap  comprised  the  skin  and  fascia,  and  the 
aponeurosis  of  the  trapezius,  and  was  reflected  outward.  Some  fibers  of  the 
rhomboid  and  of  the  serratus  posticus  were  divided,  and  these  muscles  were 
then  retracted  outward,  while  the  splenius  was  retracted  inward,  and  the 


OrKKATlONS   OX    'I'lIK   'I'lIolt.W.  1051 

transvorso  processes  of  the  vertebra'  beini,^  exposetl,  the  attaclinients  of  the 
longiijsiniiis  dorsi  were  separated  from  them,  and  all  the  deep  muscles  were 
detached  from  the  ribs  and  retracted  outward.  Portions  of  the  fcnirth,  fifth, 
and  sixth  ribs,  about  three  inches  in  length,  were  then  resected  subpeiiosteally 
from  the  tuberosities  outward.  The  layer  made  up  of  the  pei'iosteum  and 
intercostal  muscles  was  then  carefully  divided,  so  as  not  to  injure  tiie  pleura, 
the  intercostal  arteries  being  secured  as  they  were  severed.  The  pleura  was 
carefully  but  widely  detached  from  the  contents  of  the  posterior  medias- 
tinum and  from  the  posterior  chest  wall,  so  as  to  give  access  to  the  root  of 
the  lung.  The  bronchus  was  easily  reached,  but  it  was  ditiicult  to  expose  it, 
so  as  to  enable  au  incision  to  be  made  into  it,  on  account  of  the  azygos  vein 
which  crossed  it.  The  respiratory  movements  of  the  lung,  heaving  under 
the  detached  pleura,  were  also  very  embarrassing,  and  finally,  as  the  pulse 
began  to  be  affected  seriously,  the  wound  was  packed  and  the  operation 
suspended. 

"  The  following  day  the  packing  was  removed,  chloroform  being  given 
again,  and  the  pleura  being  now  somewhat  adherent  to  the  lung  and  the 
latter  less  troublesome,  the  bronchus  was  successfully  opened  on  its  posterior 
wall  without  haemorrhage.  But  even  then  our  diflticulties  were  not  com- 
pletely surmounted,  for,  to  our  great  disappointment,  it  was  found  impos- 
sible to  recognize  the  foreign  body  with  the  forcejis  introduced  into  this 
opening.  The  foreign  body,  partly  macerated,  was  similar  in  consistence  to 
that  of  the  bronchial  forks,  and  it  appeared  to  be  farther  away  from  the 
bifurcation  of  the  trachea  than  at  first.  Forceps  was  also  passed  down 
through  the  tracheal  wound,  but  still  the  foreign  body  was  not  found. 
Finally,  it  was  detected  through  the  lung  by  pressing  on  the  latter  with  the 
fingers,  and  it  was  determined  to  cut  directly  down  upon  it,  as  even  then  no 
forceps  could  be  made  to  pass  to  the  spot  where  it  lay.  The  detached  parietal 
pleura  was  first  secured  to  the  surface  of  the  lung  by  two  or  three  deep  silk 
sutures,  the  ends  of  the  latter  being  left  long,  and  the  lung  being  held  steady 
by  the  threads,  an  incision  was  made  with  the  thermo-cautery  knife.  The 
foreign  body  could  be  felt  in  this  opening,  but  it  still  eluded  the  grasp  of 
forceps,  and  the  condition  of  the  patient  forbade  any  further  delay,  so  a 
drainage  tube  was  introduced  to  the  bottom  of  the  opening  made  in  the  lung 
and  the  entire  wound  packed.  Whether  the  pin  was  too  firmly  fixed  in  the 
wall  of  a  bronchus,  or  whether  some  tissues  still  remained  undivided  over  it, 
was  impossible  to  determine,  but  if  the  ])atient  had  survived,  it  is  probable 
that  the  foreign  body  would  have  found  its  way  out  of  the  deep  wound  which 
led  directly  down  to  it.  The  patient  reacted  well,  and  on  the  following  day 
showed  only  the  ordinary  symptoms  of  a  severe  pneumonia.  Signs  of  con- 
solidation had  been  present  in  the  lower  lobe  of  the  right  lung  from  the  first, 
and  these  had  increased  daily.  Fever  and  dyspnoea,  due  to  this  consolida- 
tion, gradually  increased,  and  terminated  in  death  about  forty-eight  hours 
after  the  last  operation.  A  post-mortem  examination  showed  no  pneumo- 
thorax and  no  pleural  effusion.  The  foreign  body  lay  in  one  of  the  second- 
ary bronchi  close  to  the  end  of  the  drainage  tube,  the  pin  having  entirely 
penetrated  the  wall  of  the  bronchus." 


1052  OPERATIVE   SURGERY. 

Curtis  turned  the  base  of  the  flap  outward,  leaving  the  soft  parts  attiiched 
to  the  posterior  border  of  the  scapuUi,  thus  increasing  the  thickness  and 
mobility  of  the  base  of  the  flap.  He  resected  the  corresponding  ribs,  lessen- 
ing a  little  the  time  of  operation.  The  employment  of  the  X  rays  may  serve 
to  estal)lish  the  exact  location  of  the  obstruction,  thus  enabling  the  surgeon  to 
open  the  chest  at  a  point  nearest  to,  or  at  a  dependent  point  in  relation  with 
the  foreign  body,  unite  the  pleural  surfaces,  reach  and  remove  the  object 
through  a  canal  formed  by  cautery,  or  permit  of  direct  removal  by  means  of 
fine,  sharp-pointed,  strong  pincers  passed  through  the  intervening  living  tis- 
sues, as  has  already  been  accomplished  in  at  least  one  instance.  Tlie  writer 
submits  the  following  propositions : 

1.  That,  in  certain  cases,  when  other  means  of  relief  have  failed, 
attempted  relief  from  oesophageal  or  bronchial  obstruction  by  way  of  the 
posterior  mediastinum  may  prove  justifiable. 

2.  That  below  the  arch  of  the  aorta  the  oesophagus  is  reached  better  from 
the  right  side ;  above  the  arch  it  can  be  reached  from  either,  though  better 
from  the  left  side. 

3.  That  the  attempted  removal  of  obstructions  situated  below  the  body 
of  the  ninth  dorsal  vertebra  is  not  justifiable,  owing  to  the  great  difficulty 
and  increased  danger  of  exposing  the  esophagus  at  that  situation. 

4.  That  posterior  entrance  to  tlie  mediastinum  is  more  easily,  quickly, 
and  safely  accomplished  than  the  anterior,  and  offers  better  results  than  does 
the  latter  method  of  practice. 

The  following  valuable  deductions  of  Willard,  based  on  experiments  on 
dogs,  are  worthy  of  special  notice  in  this  connection  : 

1.  The  collapse  of  the  lung,  when  the  chest  is  02:>ened,  is  an  exceedingly 
serious  and  dangerous  element  in  the  operation,  adding  greatly  to  the  pre- 
vious shock,  and  threatening  to  overpower  the  patient. 

2.  The  difficulties  of  reaching  the  bronchus,  esiDecially  upon  tlie  left  side, 
are  exceedingly  great,  and  the  risks  of  heemorrhage  are  enormous. 

3.  The  incision  into  the  bronchus  necessarily  after  closure  of  the  wound 
of  the  chest  wall  leads  to  increasing  pneumothorax. 

4.  The  delays  in  the  operation  from  collapse  of  the  patient  must  neces- 
sarily be  great.  Rapid  work  is  impossible  when  the  root  of  the  lung  is  being 
dragged  backward  and  forward  at  least  half  an  inch  in  the  efforts  occasioned 
by  air  hunger,  and  precision  is  almost  impossible. 

5.  To  reach  the  bronchus  is  sometimes  feasible,  but  to  extract  a  foreign 
body  from  it  and  to  secure  the  patient's  recovery  is  as  yet  highly  problemat- 
ical, and  will  require  many  advances  in  technique.  The  anatomical  sur- 
roundings are  those  most  essential  to  life. 

Milton's  Operation  {Anterior  Thoracotomy). — Milton's  method  of  entrance 
to  the  thorax  contemplates  the  exposure  and  treatment  of  the  contents  of 
the  mediastina,  especially  the  anterior  and  middle,  through  an  incision 
made  in  front  at  the  median  line  of  the  chest. 

The  Operation. — Under  strict  asepsis  make  an  incision  in  the  median 
line  from  the  thyroid  cartilage  to  the  base  of  the  ensiform  cartilage,  going 
down  to  the  bone  at  the  sternal  part  of  the  cut;  expose  rapidly  the  trachea 


Ul'EKATKLNS   U.N    TllK   TIIOKAX.  1()53 

to  a  point  opposite  the  ci)istt'rniil  notch  ;  detach  the  fascia  from  the  epi- 
sternal  notch  outward  at  either  side  to  the  insertion  of  tiie  sterno-niastoid 
muscle;  separate  and  disphice  downward  with  tiie  finger  from  tiie  sternum 
the  important  structures  lying  immediately  beneath  its  ui)})er  end  ;  divide 
the  sternum  from  above  downward  nearly  through  along  the  line  of  incision 
in  the  soft  parts  with  a  saw,  omitting  the  ensiform  cartilage;  disconnect  the 
ensiform  cartilage  from  the  bone  above  with  scissors  or  bone-cutting  forceps, 
carefully  avoiding  the  underlying  structures,  especially  the  peritonajum  ; 
insert  strong,  broad-hooked  retractors  into  the  sawed  border  of  the  sternum 
at  either  side  of  the  division  and  make  moderate  traction  outward  and 
upward  ;  draw  (hjwinvard  the  ensiform  cartilage  with  a  hooked  retractor  and 
pass  from  below  upward  closely  beneath  the  sternum  along  the  saw  line  a 
spatula;  comi)lete  from  below  upward  the  severance  of  the  sternum  with 
scissors  or  bone-cutting  forceps,  cautiously  protecting  subjacent  tissues  from 
injury;  draw  with  the  retractors  and  pry  apart  with  a  broad  chisel  the 
divided  borders  of  the  sternum  sufficiently  to  expose  restraining  tissues, 
which  are  cautiously  severed  with  scissors  or  knife.  In  -this  manner  a  gap 
two  or  more  inches  in  width  is  made  through  which  the  anterior  medi- 
astinum may  be  readily  exposed  to  view  and  examination.  Exposure  and 
exploration  of  the  middle  and  even  the  posterior  mediastinum  can  now  be 
effected  after  careful  separation  of  the  pericardium  from  the  right  pleura. 
The  removal  of  morbid  growths  and  foreign  bodies  should  be  conducted 
with  consummate  care,  not  only  to  avoid  infection  and  ha?morrhage,  but  to 
obviate  fatal  injury  of  important  structures.  Blunt  dissection,  supplemented 
with  discreet  use  of  cutting  implements  in  the  effort,  should  be  practiced. 
The  closure  of  the  mediastinum  is  easily  effected  by  bringing  in  contact  the 
sawed  borders  of  bone  and  firmly  wiring  them  together  with  five  or  six  silver 
sutures.  After  the  introduction  of  gauze  drainage  at  the  upper  and  lower 
ends  of  the  sternum,  the  wound  of  the  soft  parts  is  closed  and  dressed  in  the 
usual  manner. 

The  Precautions. — For  reasons  signally  apparent  the  importance  of 
thorough  asepsis  in  each  detail  of  this  operation  can  not  be  overestimated. 
Also  the  intricate  relations  of  highly  important  structures  with  each  other 
and  with  the  sternum  are  such  as  to  demand  the  closest  thought  before 
beginning  the  operation.  Since  the  division  of  the  sternum  and  sei)aration  of 
the  bone  segments  arrest  costal  breathing,  ample  means  for  artificial  respira- 
tion should  be  at  hand  to  promptly  and  effectively  meet  respiratory  demands. 
In  emphysematous  subjects  increased  danger  of  division  of  the  pleura  is 
incurred.  If  dyspnoea  from  obstruction  is  present  at  the  outset,  tracheotomy 
should  be  performed  at  once,  and  provision  for  the  same  should  be  at  hand 
if  this  complication  be  anticipated. 

The  Remarks.— The  hardest  and  thickest  part  of  the  bone  is  at  the  upper 
end.  Separation  of  the  bone  segments  is  easier  and  safer  when  begun  at  the 
lower  end  of  the  sternum,  because  the  intrapleural  space  is  wider  (Fig.  1266, 
dotted  lines)  and  the  anatomical  relations  less  important  than  at  the  upper 
extremity  (Fig.  200).  The  chief  restraining  tissues  lie  above  near  the  in- 
nominate vein  and  below  at  the  xiphoid  junction.     Wounds  of  pleural  and 


1054: 


OPERATIVE   SURGERY. 


peritoneal  membranes,  especially  the  former,  should  be  closed  immediately 
by  pressure  to  avoid  pulmonary  collapsing  and  possibly  a  fatal  issue.  Im- 
mediate artificial  respiration  should  be  utilized  in  lung  collapse.  "Wounds 
of  each  of  these  structures  should  be  closed  by  sewing  as  promptly  as 
possible.  Morbid  processes  involving  the  sternum  should  be  removed  when 
practicable  the  same  as  if  elsewhere  located.  The  unavoidable  amount  of 
haemorrhage  is  insignificant. 

TJie  Results. — The  outcome  of  the  several  operations  by  this  method 
commend  its  further  employment,  especially  when  directed  to  morbid  states 
of  the  anterior  and  middle  mediastina. 

OPERATIOXS    ox    THE    HEART    AND    PERICARDIUM. 

ISTot  until  quite  recently  has  this  field  of  operative  effort  been  given  the 
consideration  commensurate  with  its  great  importance. 

The  Anatomical  Points. — The  heart  corresponds  in  front  to  the  lower 
two  thirds  of  the  sternum,  and  parts  of  the  adjacent  costal  cartilages  and  of 
some  of  the  left  ribs.     Its  upper  limit  is  at  about  the  third  costal  cartilages, 

its  apex  at  a  point  located  three 
quarters  of  an  inch  within  and 
one  inch  and  a  half  below  the 
nipple.  It  extends  three  inches 
to  the  left,  and  about  one  inch 
and  a  half  to  the  right  of  the 
median  line  of  the  sternum.  Be- 
hind the  sternum  are  situated 
more  than  two  thirds  of  the 
right  ventricle,  the  right  auricle, 
a  large  part  of  the  left  auricle. 

Fig.  1263.— Vertical  section  showing  relations  of    and    a    portion    of    the    anterior 
the  heart  and  a  considerable  pericardial  effu- 
sion to  the  parietes;  reclining. 


a.  Cul-de-sac. 


7.  Seventh  costal  cartilage. 


coronary  vessels.  The  base  of 
the  heart  corresponds  at  the  back 
to  the  sixth,  seventh,  and  eighth 
dorsal  vertebrae.  The  anterior  portion  of  the  pericardium  above,  lies  from 
three  to  five  centimetres  (one  and  two  tenths  to  two  inches),  and  below 
about  one  centimetre  (four  tenths  of  an  inch)  behind  the  sternum.  At  the 
base  of  the  pericardial  sac  anteriorly  there  is  a  cul-de-sac  (a)  of  from  one  to 
two  centimetres  (four  to  eight  tenths  of  an  inch)  in  depth,  normally  col- 
lapsed, but  distended  in  the  event  of  pericardial  effusion,  when  it  corre- 
sponds to  the  region  of  the  sixth  intercostal  space  (Fig.  12G3).  Toward 
this  cul-de-sac  (a)  are  the  efforts  of  the  operator  directed  in  aspiration  and 
in  drainage  of  the  pericardium.  The  distended  pericardium  extends 
above  to  the  first  space,  below  to  the  seventh  cartilage,  to  the  right  from 
two  to  three  centimetres  (eight  tenths  to  one  and  two  tenths  inches) 
beyond  the  edge  of  the  sternum,  and  to  the  left  a  little  beyond  the  nor- 
mal line.  At  the  interpleural  space  the  pericardium  can  be  entered  with- 
out involvement  of  the  pleura.  This  space  corresponds  to  the  lower 
triangular  portion  of  the  anterior  mediastinum,  and  is  bounded  on  either 


OPERATION'S   ()X    'I'llK    TIKJltAX. 


1055 


sido  i)V  the  respective  anterior   ])l('iiral    rellections,  and  below  by  the  dia- 
phragm (Fig.  1264). 

Tiic  exact  location  and  size  of  this  .space  vary.     Kight  pleural  adhesion."? 
or  a  left  pleurisy  with  eifusiou,  carries  the  space  to  the  right  of  its  nor- 
mal  position,  and  vice  versa.     Adhe- 
sions of  both  pleune  increase  the  size 


Fig.  12G4. — Composite  normal  interpleural 
space  of  Voinitch-Sianojentsky.  a.  Re- 
sultant line  of  greatest  safety,  b.  Me- 
dian line.  5,  6,  7.  Fifth,  sixth,  and 
seventh  costal  cartilages. 


Fig.  126.5. — Internal  mammary  artery  lying 
on  triangularis  sterni  muscle,  a.  Artery. 
h.  Muscle. 


of  the  interpleural  space,  while  a  double  jDleurisy  with  effusion  diminishes 
the  space  and  presses  the  pericardium  backward.  In  abdominal  distention 
the  diaphragm  or  lower  boundary  of  the  interpleural  space  is  pushed  upward, 
so  that  a  puncture  of  the  fifth  space  might  enter  the  abdominal  cavity.  A 
pericardial  effusion,  other  things  being  equal,  tends  to  increase  the  size  of 
the  interpleural  space.  The  anterior  pleural  folds  are  loosely  adherent  to 
the  pericardium,  from  which  they  can  be  stripped,  but  intimately  bound  to 
the  triangularis  sterni,  from  which  they  can  not  be  separated.  A  ridge  of 
dense  cellulo-adipose  tissue  designates  the  line  of  pleural  reflection.  The  tri- 
angularis sterni  underlies  the  sternum  and  costal  cartilages.  Upon  it  rests 
the  internal  mammary  artery  (Fig.  1265),  which  above  lies  from  one  half  to 
one  and  a  half  centimetres  (two  to  six  tenths  of  an  inch),  and  below  from 
one  to  two  centimetres  (four  to  eight  tenths  of  an  inch)  from  the  sternal 
border.  A  cartilaginous  bridge  unites  the  sixth  and  seventh  costal  cartilages 
(Fig.  1266,  d),  and  sometimes  one  exists  also  between  the  fifth  and  sixth. 
The  sixth  space  near  the  sternum  is  a  very  narrow  one,  and  is  sometimes 
obliterated. 

Aspiration  of  the  Pericardium. — This  operation  is  performed  for  hydro- 
pericardium,  ha?mopericardium,  and  for  diagnosis  in  suspected  pyoperi- 
cardium.  The  needle  should  be  a  very  fine  one  for  diagnosis.  That  of 
Pravaz  is  much  employed.  Evacuation  should  be  done  with  a  Potain  appa- 
ratus and  a  needle  or  trocar. 


1056 


OPERATIVE   SURGERY. 


Tlie  Important  Facts. — Involvement  of  tlie  pleura  and  injury  to  the  heart 
and  internal  mammary  vessels  should  be  avoided.  The  determination  ante- 
riorly of  a  composite  pericardial  area  not  covered  by  pleura  in  any  one  of  a 
large  number  of  normal  subjects  has  been  made  by  Voinitch-Sianojentsky 
(Fig.  12G4).  The  long  axis  of  this  space  which  would  be  the  resultant  site 
of  greatest  safety  extends  from  the  seventh  left  chondro-sternal  articulation 
vertically  upward  to  the  level  of  the  lower  border  of  the  fifth  chondro-sternal 
articulation.  This  line  lies  chiefly  behind  the  sternum  but  touches  upon  the 
sixth  space,  just  at  the  sternal  margin.  The  same  investigator  likewise 
demonstrates  the  relation  of  the  heart  surrounded  by  a  considerable  effusion 
to  the  chest  wall  (Fig.  1263).  This  illustrates  how  puncture  in  the  sixth 
space  can  be  made  direct,  and  also  that  in  puncture  througli  the  fifth  space 
the  puncturing  agent  should  be  directed  very  obliquely  downward  to  avoid 

injury  to  the  heart.  The  mammary 
vessels  can  be  avoided  by  punctur- 
ing close  to  the  sternum  or  well  ex- 
ternal to  them. 

The  methods  of  asijiration  are 
those  of  Delorme  and  Mignon,  of 
Baizeau  and  Delorme,  of  Voinitch- 
Sianojentsky,  and  of  Dieulafoy  (Fig. 
1266). 

Delorme  and  Mignon. — Make  a 
vertical  incision  at  the  left  border  of 
the  sternum  over  the  fifth  and  sixth 
intercostal  spaces.  Introduce  the 
needle  preferably  in  the  sixth  space, 
but  if  this  space  is  too  narrow, 
through  the  fifth,  close  to  the  ster- 
num for  about  eight  millimetres 
(three  tenths  of  an  inch),  corre- 
sponding to  the  thickness  of  the 
bone ;  then  direct  the  needle  inward 
close  to  the  posterior  surface  of  the 
sternum  for  one  or  two  centimetres 


Pig.  126R. — Aspiration  of  the  pericardium. 
a.  Anterior  edge  of  hing.  b.  Border  of 
pleura,  c.  Internal  mammary  artery,  d. 
Cartilaginous  bridge  between  sixth  and 
seventh  cartilages.  Sites  of  Puncture. — 
1.  Baizeau  and  Delorme.  :2.  Delorme  and 
Mignon,  also  Voinitch-Sianojentsky.  3, 
3' .  Dieulafoy.  Dotted  lines  correspond 
to  borders  of  pleura. 


(four  or  eight  tenths  of  an  inch),  to  avoid  the  pleura,  after  which  raise  the 
handle  of  the  instrument  a  little  and  plunge  the  needle  downward  and 
inward  through  the  pericardium. 

Baizeau  and  Delorme  (1). — Through  a  short  skin  incision  plunge  the 
needle  obliquely  downward  and  inward  in  the  fifth  left  intercostal  space, 
close  to  the  sternum,  until  the  pericardium  is  reached  and  entered, 

Vo'initch-Sianojentshy  {2). — Pass  the  needle  directly  from  before  back- 
ward in  the  sixth  left  intercostal  space  close  to  the  sternum. 

Dieulafoy  (5). — Aspiration  is  made  through  the  fourth  or  fifth  space, 
preferably  the  latter,  at  a  point  about  six  centimetres  (two  and  four  tenths 
inches)  from  the  sternal  margin.  Entering  by  a  short  vertical  incision  pass 
the  point  of  the  needle  carefully  through  the  intercostal  muscles,  after  which 


OPKRATIONS   OX    'I"I1K   'I'lloKAX,  1057 

direct  the  instninu'iit  ol)li<iiH'ly  inward,  uliiiost  i)arallrl  witli  the  inner  surface 
of  the  chest  wall.  The  tense  surface  of  the  pericardium  is  detected  and  the 
instrument  passed  through  it.  The  point  of  the  instrument  should  he  care- 
fully held  downward  and  inward,  llattened  against  the  j)ericardial  sac  to 
prevent  injury  of  the  heart. 

The  Renuirks. — Lejars  recommends  the  method  of  Baizcau  and  Delorme 
for  diagnostic  puncture.  The  ohjections  to  the  method  of  Dieulafoy  are 
that  the  instrument  always  i)asses  through  the  pleura,  and  that  the  heart, 
from  its  relation  with  the  fifth  space,  is  liable  to  be  injured.  Owing  to  the 
pleural  involvement,  aspiration  should  never  be  practiced  here  for  pus. 

Tlie  Results. — The  results  of  aspiration  in  hoemorrhagic  pericarditis, 
where  the  general  condition  is  not  too  unfavorable,  are  good.  In  pericar- 
ditis with  effusion  the  results  vary  according  to  whether  the  fluid  is  of  a 
tuberculous  or  of  a  rheumatic  origin.  Early  as])iration  here  is  better  than 
late.  In  the  hydropericardium  of  Bright's  or  cardiac  disease,  aspiration  can 
be  only  a  palliative  measure. 

Pericardiotomy. — Pericardiotomy  is  performed  for  exploration  in  wounds 
of  the  pericardium,  for  suture  of  wounds  of  the  heart,  and  for  drainage  of 
pus. 

The  Operation. — Make  either  an  x-shaped  incision  (Fig.  963)  or  a  single 
oval  incision  with  its  base  at  the  sternum.  The  vertical  portion  of  the 
former  should  lie  a  finger's  breadth  external  to  the  left  border  of  the  sternum, 
and  extend  from  the  upper  border  of  the  fourth  to  the  lower  border  of  the 
sixth  or  seventh  cartilage.  The  fifth  cartilage  is  always  resected,  and  the 
sixth  and  fourth  also  may  be  if  more  space  be  needed.  Cut  the  intercostal 
muscles  close  to  the  sternum  and  reflect  the  flap  outward,  exposing  the  inter- 
nal mammary  artery  beneath.  Tlie  latter  may  either  be  ligated,  or  else 
drawn  outward  together  with  the  triangularis  sterni  and  the  left  pleural 
reflection,  after  the  dissection  of  these  structures  from  the  sternum  and 
pericardium  respectively.  Incise  the  pericardium  from  below  upward  be- 
tween two  forceps  to  avoid  injury  of  the  heart.  Drain  at  the  lower  angle  of 
the  wound.  In  suture  of  the  pericardium  bring  serous  surfaces  into  appo- 
sition. 

The  Remarks. — This  operation  is  practically  that  of  Delorme  and 
Mignon.  Voinitch-Sianojentsky  has  proposed  three  operations  for  drainage 
of  a  small,  a  medium,  and  a  large  effusion  respectively,  aiming  his  point  of 
entrance  at  the  interpleural  space  which  he  found  enlarged  progressively 
toward  the  left  with  the  increase  in  pericardial  fluid.  For  a  small  effusion 
he  would  resect  the  left  sixth  and  seventh  cartilages  close  to  the  sternum, 
together  with  the  adjacent  jDortion  of  the  sternum,  and  sew  the  pericardium 
to  the  aponeurotic  opening  in  the  triangularis  sterni.  For  a  medium  effu- 
sion he  would  resect  the  left  sixth  and  seventh  cartilages  adjacent  to  the 
sternum  without  resection  of  the  sternum  itself,  tying  the  internal  mam- 
mary artery ;  and  for  a  large  effusion  he  would  resect  the  sixth  left  cartilage 
external  to  the  internal  mammary  artery. 

Wounds  of  the  Heart. — Wounds  of  the  heart  are  not  so  infrequent  or  so 
fatal  as  is  commonly  supposed.     Death  may  happen  instantly  or  be  delayed 


1058  OPERATIVE   SURGERY. 

for  many  months.  Fischer  collected  452  cases  with  84.07  per  cent  mortal- 
ity; 104  of  these  cases  suffered  immediate  death.  Loisoii  reports  277  cases 
of  the  past  thirty  years,  with  84.8  per  cent  mortality.  Jamain  reports 
121  cases,  of  which  18  per  cent  died  immediately,  G9  per  cent  died  after 
an  interval  of  more  or  less  time,  and  13  per  cent  recovered.  Laforgue 
reports  56  cases,  of  which  32  per  cent  died  immediately,  38  per  cent 
survived  for  a  longer  or  shorter  period,  and  30  per  cent  recovered. 
Loison  reports  23  cases  of  needle  wound  of  the  heart  with  14  deaths, 
of  which  1  only  was  from  infection.  Eight  deaths  certainly,  and  prob- 
ably the  others,  were  from  tearing  of  the  heart,  and  in  all  there  was  dis- 
tention of  the  pericardium.  Tlie  right  ventricle,  from  its  anterior  posi- 
tion, is  the  part  most  often  wounded.  The  auricles,  especially  the  left, 
may  be  wounded  from  the  back.  In  a  wound  of  the  heart  the  pleura  is 
almost  always  involved,  producing  a  left  hemothorax.  Rehn  and  Bode 
claim  that  small  wounds  of  the  heart  tend  to  heal  rapidly,  while  large 
wounds  remain  gaping,  having  a  tendency  to  enlarge  in  the  direction  of 
the  muscle  fibers. 

In  estimating  the  possibility  of  injury  of  the  heart  from  penetrating 
agents,  the  seat,  depth,  and  direction  of  the  wound  are  of  the  greatest  impor- 
tance. These  facts,  when  supplemented  by  a  knowledge  of  the  established 
relations  of  the  organ  to  the  chest  wall,  enable  one  to  judge  quite  accurately 
by  local  evidence  only  if  the  heart  be  wounded. 

When  the  local  characteristics  of  the  wound  suggest  that  the  heart  is 
involved,  absolute  quiet,  in  as  comfortable  a  posture  as  possible,  should  be 
enjoined  and  secured  if  practicable  by  anodynes.  If  symptoms  are  present  or 
supervene  indicating  labored  action  of  the  organ  from  impaired  force  due  to 
injury,  or  to  direct  pressure  from  pericardial  extravasation  of  blood,  the  heart's 
power  should  be  stimulated  and  the  labor  lessened  by  removal  of  the  extrav- 
asated  fluid  and  the  arrest  of  ha?morrhage.  Paget  rejiorts  a  case  of  stab 
wound  complicated  with  great  distention  of  the  pericardium  by  blood,  and 
attended  by  severe  suffering,  in  which  a  successful  issue  followed  phlebotomy. 
The  patient's  condition  improved,  the  profound  sense  of  suffocation  dimin- 
ished as  the  escape  of  blood  progressed  to  the  estimated  amount  of  two 
pounds.  Should  bleeding  fail  to  afford  relief,  and  evidences  of  increasing 
escape  obtain,  the  removal  of  the  compressing  fluid  by  tapping  or  incision 
of  the  pericardium  under  local  anaesthesia  is  indicated,  followed  possibly  in 
the  latter  instance  by  repair  of  the  wound  itself  (page  1059).  If  blood  escape 
from  the  pericardial  wound  the  latter  should  not  be  tamponed,  since  not 
only  is  the  circulation  depleted  by  the  flow,  but  also  the  danger  of  compres- 
sion of  the  heart  is  diminished  by  it. 

In  the  instance  of  needle  wounds  the  onset  of  the  symptoms  is  less  acute, 
more  slowly  progressive,  and  not  so  dangerous  as  in  wounds  from  grosser 
agents.  A  simple  puncture  of  the  heart  is  comparatively  harmless,  but 
when  a  needle  is  left  with  one  end  fixed  in  tlie  thoracic  wall  and  the  other 
planted  in  the  pulsating  heart  a  gradual  tearing  of  the  cardiac  muscle  takes 
place.  Immediate  extraction  is  therefore  indicated.  The  detection  of  the 
point  of  penetration,  and  of  the  needle  itself,  by  means  of  the  X  rays,  call 


()i'i:i;.\'i'i()Ns  ox  TiiK  Ni:('K.  I059 

for  oxj)loriitivo  c.Xiuniiuition  iiiul  rcinovul.  'J'lio  needle  should  be  removed 
with  ii  slow,  steady,  rotatory  inoveiuent. 

The  Siititre  of  Wounds  of  the  Heart. — The  licart  has  been  sutured  six 
times  ill  man,  twice  successfully,  once  by  Heh)!,  who  sutured  a  wound  of 
one  and  a  half  centimetres  (six  tenths  of  an  inch)  in  the  ri<,dit  ventricle  with 
three  silk  sutures,  and  once  by  ]\(rozani,\\\\o  sutured  a  wound  of  two  centi- 
metres (eii^'ht  tenths  of  an  inch)  at  the  apex  with  four  sutures.  Giordani 
sutured  a  wound  of  two  centimetres  (eight  tenths  of  an  inch)  in  the  left 
auricle  with  four  sutures,  and  found  the  wound  in  the  process  of  cicatrization 
at  autojjsy,  death  having  resulted  on  the  nineteenth  day  from  empyema. 

A  curved  intestinal  needle  is  used.  It  is  carried  deeply  into  the  cardiac 
muscle,  entering  and  emerging  on  either  side  of  the  wound  at  least  four  or 
five  millimetres  (one  tenth  and  a  half  or  two  tenths  of  an  inch)  from  its 
edges,  and  should  never  penetrate  the  endocardium.  It  is  passed  rapidly 
during  diastole,  which  is  perceptibly  lengthened  by  the  manipulation.  At  a 
succeeding  diastole  the  thread  is  drawn  through,  and  at  another  tied.  Trac- 
tion on  the  first  stitch  facilitates  the  introduction  of  the  successive  ones  by 
steadying  the  heart.  It  is  best  to  suture  all  wounds  of  the  heart.  The 
coronary  artery  if  wounded  should  be  tied. 

OI'EIIATIOXS    ox    THE    XECK. 

Bronchotomy. — The  expression  bronchotomy  includes  four  distinct  opera- 
tions :  l((ri/)igotoiuy,  tracheotomy,  laryngo-tracheotomy,  and  thyrotomy,  the 
first  two  of  which  are  still  further  classified.  These  operations  are  compar- 
atively easy  in  the  adult,  especially  if  the  neck  be  long  and  thin,  and  the 
landmarks  well  developed.  In  the  infant  and  the  child,  and  before  puberty 
— the  periods  of  life  when  they  are  most  demanded — their  performance  is 
difficult  and  perplexing,  owing  to  the  shortness  of  the  neck,  obesity  of  the 
patient,  the  rudimentary  condition  of  the  landmarks,  and  the  exigencies  of 
the  occasion. 

The  Anatomical  Points. — The  trachea  in  the  adult  is  about  four  inches 
and  a  half  in  length  and  three  quarters  of  an  inch  from  side  to  side.  The 
distance  between  the  sternum  and  the  cricoid  cartilage  is  about  two  and 
three  quarter  inches  in  the  adult,  and  two  and  a  quarter,  two,  and  one  and 
a  half  at  ten,  seven,  and  five  years  respectively.  The  following  illustrative 
scheme  (Treves)  shows  the  relation  between  the  respective  ages  and  sizes  of 
the  corresponding  tubes  (Fig.  1267)  : 

00009 

a  h 

Fig.  1267.— Comparative  diameters  of  tracheotomy  tubes  based  on  age  of  patients,  a. 
.47  +  inch  (12  mm.),  twelve  to  fifteen  years.  '  b.  .40  —  inch  (10  mm.),  eight  to  ten 
years,  c.  ..31  +  inch  (8  mm.),  four  to  eight  years,  d.  .24  —  inch  (6  mm.),  two  to  four 
years,  e.  .20  —  inch  (5  mm.),  one  and  a  half  to  two  years.  Adults,  i  to  i  inch ; 
under  one  year  and  a  half,  .1.5  +  inch. 

The  thyroid  cartilage  (Pig.  1268,  c),  which  is  well  marked  in  the  adult,  con- 
stituting a  prominent  point  of  reckoning,  is  scarcely  discernible  in  the  child, 
73 


1060  OPERATIVE  SURGERY. 

and  iu  the  infant  it  is  quite  impracticable  to  determine  its  location  by  physical 
examination.  The  cricoid  cartilage  (e)  is  a  far  better  guide  by  which  to  deter- 
mine the  comparative  relations  of  the  parts.  It  is  the  distinctive  cartilage  of 
the  laryngeal  group,  and,  irrespective  of  age,  it  can  be  felt  as  a  firm,  round 
ring,  much  more  prominent  than  the  cartilaginous  rings  of  the  trachea,  which 
lie  immediately  below  it.  The  crico-thyroid  space  {d),  through  which  in 
laryngotomy  the  deeji  incision  is  made,  is  located  immediately  above  the 
cricoid  cartilage  (Fig.  12G8).  This  space  is  situated  at  the  bottom  of  the  first 
groovelike  depression  above  the  cricoid  cartilage.  The  crico-thyroid  mem- 
brane {d)  is  composed  of  yellow  elastic  tissue,  is  therefore  of  a  yellowish 
appearance,  and  is  often  dotted  by  openings  for  small  vessels.  When  incised 
it  will  retract,  owing  to  its  resilient  nature  ;  hence  all  haemorrhage  should  be 

stopped  before  it  is  opened  if  the  urgency  of 
the  case  will  permit.     It  is  not  difficult  to 
//2il«v\  locate  the  guides  in  the  dead  subject  under 

■  h      ordinary  circumstances  ;   but  in  the  living, 
when  they   are   being  jerked   upward    and 
-^      downward  by  the  efforts  of  impeded  respira- 
tion, it  is  a  matter  of  great  difficulty,  and 

d  - fiJ^IS^iiji^S^u "  may  be  impossible.     The  only  artery  nor- 

[V.K JP^  mally  in  the  line  of  the  ojieration  of  laryn- 

;^ga>-in.j!m  \      -^-^■^m-irr--^^' J'     gotomy  that  need  be  respected  is  the  crico- 
thyroid (Fig.  12G9,  d) ;    it   runs  along   the 
,  upper   border  of  the  space,  resting  oii  the 

membrane  of  the  same  name.    This  artery  is 
,  JWi^^^M'-'//  troublesome,  not  from  the  amount  of  blood 

it  contains,  but  from  its  relation  to  the  open- 
ing in  the  membrane  through  which  a  small 
amount  of  blood  may  pass  into  the  tube. 
The  vessels  causing  the  greatest  annovance 

Fig   1268.-The  topography  of  the   _especiallv  if  the  initient  be  much  cvanosed 
larynx,   etc.      a.  isodv   oi  hvoid  i  .  x 

bone.  b.  Thyro-hyoidmembrane.  — are  the  small  venous  trunks  which  run 
c.  Thyroid  cartilage,  d.  Crico-  across  the  tracheal  and  larvngeal  region, 
thyroid  membrane.      e.    Cricoid  i    /-    •     i  ^  ^''•  ^     ■,       i     • 

cartilage.  /.  First  tracheal  ring,  without  any  definitely  established  relation- 
g.  Isthmus  of  thyroid  body,  with  ghip,  and  which  return  their  blood  chiefly 
tracheal  rings  below.      //.  C'rico-    .    ^      ,-,  ■        -i         -i        •       /-t'-       i^nr,\ 

thyroid  muscle.  "^^o  the  superior  thyroid  veins  (rig.  1209). 

The  anterior  jugular  veins  will  be  trouble- 
some unless  the  median  line  be  adhered  to  closely.  It  is  unnecessary,  I  trust, 
to  allude  to  the  well-known  relation  between  the  larynx  and  the  large  vessels 
of  the  neck.  The  tliymus  gland  in  the  very  young  deserves  respectful 
mauipulative  consideration.  The  innominate  and  common  carotid  arteries^ 
especially  in  the  right,  may  encroach  on  the  operation  in  low  tracheotomy. 

The  uncesthetic  to  be  given  in  operations  where  the  respiratory  function 
of  the  larynx  is  involved  is  a  matter  entitled  to  careful  consideration.  For 
instance,  if  ether  be  given  to  one  who  has  no  laryngeal  irritation  or  obstruc- 
tion, the  frequent  spasn.  of  those  parts  is  familiar  to  all.  If  to  this  be  added 
the  deficient  aeration  of  the  blood,  due  to  a  laryngeal  obstruction,  together 


Ol'KliA'I'loNS   ()\    TIIK    \i;("K. 


1(m;i 


V 


with  tlic  increased  tendeucy  to  spu.siii,  dependent  on  laryngeal  disease  and  to 
fright,  then  is  tiu'  (hmgur  of  asphyxia  greatly  augmented.  Chloroform  may 
be  given  with  but  litik;  danger  of  eausing  spasm;  if  ether  be  administered, 
it  must  be  eoninu'iued  very  gradually,  to  avoid  as  much  as  i)0ssible  the 
oeeurrence  of  laryngeal  spasms.  In  many  instances  the  pressing  nature  of 
the  case  will  not  per- 
mit the  expenditure  of 
the  time  necessary  to 
produce  general  ana3S- 
thesia.  Local  anaes- 
thesia may  be  em- 
ployed. In  those  cases 
presenting  marked  cy- 
anosis the  sense  of 
pain  is  much  blunted 
and  the  operation 
should  be  done  with- 
out anaesthesia.  IVie 
instrvitieiits  suitable 
for  these  operations 
(F'ig.  12  TO)  are  quite 
numerous,  yet  the  ab- 
sence of  any  one  or 
more  of  them  is  not 
to  be  considered  a 
reason  for  non  -  per- 
formance  of  bronchot- 
omy  when  demanded. 
When  necessary,  a 
pocketknife,      and     a 

hairpin,  a  toothpick,  or  a  catheter  (Fig.  1270)  can  be  extemporized  to 
advantage,  thus  preventing  the  death  of  the  patient  unaided  because  a 
tracheotomy  tube  is  not  obtainable. 

Langenbeck's  hook  (Fig.  1271)  is  the  best  in  use,  because  the  line  of  the 
cut  can  be  made  between  its  blades,  and  the  middle  line  of  the  trachea  is 
therefore  the  better  assured.  There  are  various  forms  of  tracheotomes, 
which  should  not,  in  our  opinion,  be  substituted  for  the  sharp-pointed 
bistoury,  because  they  are  much  less  surgical  in  their  inception  and  far 
more  dangerous  in  their  use.  Trachea  dilators,  too,  are  quite  numerous 
and  varied  in  pattern  (Fig.  1270, /;,  rj,  ;•),  The  borders  of  the  tracheal  open- 
ing can  always  be  easily  drawn  apart  by  common  tenacula  or  by  two  of  the 
ordinary  grooved  directors  with  aneurism-needle  attachments  (Fig.  1270,  e). 
The  bivalve  trachea  tube  is  an  admirable  instrument,  since  it  can  be  intro- 
duced through  the  opening  in  the  trachea  much  more  readily  than  the  oi'di- 
nary  blunt-ended  pattern,  and  can  be  quickly  opened  afterward  by  the  intro- 
duction into  it  of  the  companion  tube  (Fig.  1270,  ?i).  A  long  feather,  with 
the  end  of  the  brush  remaining  (Fig.  1270,  u),  should  be  at  hand  to  insert 


F[G.  1269. — The  surgical  anatomy  of  larvnx  and  tracliea.  a. 
Thyroid  cartilage,  b.  Crico-thyroid  membrane  and  ar- 
tery, crico-thyroid  muscle  at  either  side.  c.  Cricoid  car- 
tilage, d.  Superior  thyroid  vein.  e.  Inferior  thyroid 
vein.  /.  Innominate  artery.  g.  Thymus  gland.  Ii. 
Sterno-hyoid  muscle,  i.  Omo-hyoid  muscle.  J.  Sternal 
attachment  of  sterno  -  mastoid.  A-.  Jugular  vein  and 
branches.  Z,  /.  Carotid  arteries  and  branches,  m.  Ster- 
num.    71.  Tlivroid  bodv. 


Fig.  1270.— Instruments  employed  in  operations  on  the  trachea. 
a.  Scalpels,  sharp  and  probe  pointed,  b.  Scissors,  curved  and  straight,  bhmt  jjointed.  c. 
Forci pressure,  d.  Mouse-tooth  forceps,  e.  Directors  with  hooked  extremities.  /. 
Blunt  hook.  g.  Strong  tenaculum.  /(.  Two-tined  retractor,  i.  Small  blunt  re- 
tractor. A-.  Rubber  tracheotoiuv  tube  with  tapes  attached.  I.  Hard-rubber  tube.  m. 
Gussenbauer's  tube.  n.  Bivalve  tube.  o.  Konig's  tube.  p.  Trousseaus  trachea 
dilator,  q.  Tiemann's  dilator,  r.  Chassaignac's  dilator,  s.  Hairpin,  pocketknife, 
and  female  catheter,  f.  Trachea  forceps,  u.  Feather  for  introduction  to  trachea,  v. 
Trachea  forceps,  w.  Trachea  aspirator,  x.  Ligatures,  traction  loops,  and  sutures. 
Spatula,  mouth  gag,  tongue  forceps,  wipers,  and  shield,  for  mouth  and  eyes  of  oi)era- 
tor  in  diphtheria,  ought  to  be  at  hand.  Genzmer's  niodification  of  Konig  s  tube  (o)  is 
valuable. 

1063 


()|'i:i;a'I"1().\s  (».\  tiik  nikk. 


1003 


tlirough  thu  tube  into  the  Lruclica,  Lu  creuto  tliu  irriLutiou  sometimes  neces- 
sary to  cause  tlie  expulsion  of  the  tracheal  mucus.  A  so-called  trachea  aspi- 
rator has  been  devised  to  remove  mucus  and  blood  from  the  trachea  (Fig. 
12iO,  w).  It  is  used  as  follows:  After  the  insertion  of  the  trachea  tube, 
place  the  thiiinl)  on  the  air  liole  of  the  ban'el  ;  apply  the  soft-rubber  cup  over 
the  tube,  anil  witlidraw  the  i)iston,  when  the  mucus  and  blood 
will  enter  the  barrel.  It  has  not  infrequently  ha{)pened  that  a 
patient  is  unable  to  exjx'l  the  blood  and  mucus  on  account  of 
stupor  or  weakness,  and  the  lips  of  the  operator  were  used  to 
clear  the  trachea.  This  is  obviously  a  hazardous  procedure  if 
the  patient  have  syphilis  or  diphtheria.  The  possession  of  the 
tracheal  aspirator  will  be  welcomed  as  preferable  under  all  cir- 
cumstances. A  serviceable  instrument  for  the  purpose  of  re- 
moving blood,  etc.,  from  the  trachea  tube,  and  even  from  the 
trachea  itself,  can  be  quickly  extemporized  by  attaching  to  the 
nozzle  of  an  ordinary  two-ounce  rubber  syringe  a  soft  piece 
of  rubber  tubing  live  or  six  inches  in  length.  The  unattached 
end  of  the  rubber  tubing  is  inserted  into  the  trachea  tube  or 
into  the  trachea  itself ;  the  piston  of  the  syringe  is  withdrawn 
somewhat  quickly,  and  the  fluid  sucked  up.  If  the  suction 
be  made  too  quickly  the  tube  will  be  collapsed  and  inopera- 
tive. Large  portions  of  membrane  have  been  drawn  by  the 
writer  from  the  bronchial  tubes  in  this  manner. 

The  After-treatment. — The  soft  parts  above  and  below  the 
tube  are  closed  by  sutures  and  the  patient  is  then  placed  in  bed 
and  caused  to  breathe  air  saturated  with  warm  vapor  from 
which  all  floating  particles  of  dirt  should  be  excluded.  The 
tube  is  carefully  watched  to  prevent  it  from  becoming  closed, 
and  occasionally  removed  and  cleansed  to  prevent  wound  and 
pulmonary  infection.  Too  great  emphasis  can  not  be  laid  upon 
the  necessity  of  instantly  relieving  the  sudden  occlusion  of  the 
tube  due  to  false  membrane.  For  this  reason  a  momentary  inattention,  as 
leaving  the  room,  etc.,  may  prove  fatal  to  the  patient.  After  three  or  four 
days  the  tube  may  be  removed  and  the  patient  allowed  to  breathe  through 
the  opening  for  a  few  hours,  after  which  the  tube  should  be  again  inserted  ; 
later  in  the  case  it  may  be  inserted  only  during  the  night.  As  soon  as  the 
patient  can  breathe  well,  the  tube  should  be  removed  entirely,  the  opening 
cleansed,  and  the  borders  closed,  joined  by  sutures.  If  antiseptic  gauze 
(not  bichloride)  be  placed  between  the  surface  of  the  neck  (Fig.  127."))  and 
the  flanges  of  the  tube,  the  danger  of  irritation  of  the  soft  parts  at  that  situ- 
ation by  the  discharges  will  be  obviated. 

Laryngotomy. — Although  all  operations  in  which  the  larynx  is  opened 
are  included  under  the  name  laryngotomy,  for  convenience  of  expression 
limited  divisions  of  the  organ  are  named  for  the  part  divided — i.  e.,  thyrot- 
omy,  cricotomy  (Figs.  1372  and  1273),  etc. 

Tlte  Operation. —  Place  the  patient  on  the  table  with  the  shoulders  ele- 
vated, head  thrown  back,  and  neck  exposed  to  a  strong  light.     If  hurried,  a 


Fig.  1271. 
Laiigenbeck's 
double  hook. 


ior,4 


OPERATIVE   SURGERY. 


round  bottle  or  loaf  of  bread  or  block  of  wood  may  be  placed  under  the  neck, 
or  if  the  head  hang  sui)])orted  over  the  edge  of  the  bed  or  table,  the  object 

will  be  gained.  At  least 
three  assistants  are  re- 
quired, especially  if  an 
anaesthetic  be  given.  Lo- 
cate the  cricoid  cartilage ; 
support  the  larynx  firmly 
between  the  thumb  and 
finger  of  the  left  hand  ; 
make  an  incision  through 
the  integument  one  inch 
and  a  half  in  length  in 
the  adult,  terminating  at 
the  lower  border  of  the 
ricoid  cartilage  ;  divide 
the  fascia  on  a  director ; 
.  '  divide  the  connections 
between,  and  separate  the 
borders  of  the  sterno-hyoid 
(Fig.  12G9)  muscles  with 
retractors ;  push  aside  the 
veins  and  connective  tis- 
sue and  the  crico-thyroid 
membrane  will  be  seen  (b). 
If  the  case  be  not  urgent,  check  all  haemorrhage  before  opening  the  larynx. 
If  otherwise,  open  it  at  once,  when  the  entrance  of  air  and  the  resump- 
tion of  the  respiratory  functions  will  dispel  the  cyanosis  and  check  the 
bleeding.  The  larynx  is  seized  and  held  firmly  upward  and  forward  by  the 
tenaculum,  while  the  opening  is  made  through  the  crico-thyroid  membrane, 
transversely  near  the  upper  border  of  the  cricoid  cartilage,  both  to  avoid  the 
crico-thyroid  artery,  which  runs  along  the  upper  border  of  the  membrane 
near  the  thyroid  cartilage,  and  also  to  remove  the  tube  as  far  as  possible 
from  the  vocal  cords.  The  whistling  of  the  ingoing  air,  succeeded  by  an 
expulsive  cough — which  ejects  the  mucus,  blood,  and  other  matters — follow 
quickly  after  the  incision.  If  the  operation  be  performed  for  the  removal 
of  a  foreign  body  it  may  at  this  time  be  expelled,  or  become  lodged  near  the 
opening,  when  it  can  be  removed  by  forceps.  If  the  operation  be  performed 
for  laryngeal  diphtheria,  the  tube  should  not  be  inserted  until  all  loose 
membrane  has  been  expelled,  and  such  as  may  be  within  reach  of  the  for- 
ceps has  been  pulled  away.  If  blood  escape  into  the  opening  from  the 
oozing  vessels,  the  pressure  of  the  tube  upon  the  lips  of  the  wound  will 
serve  to  check  it,  and  for  this  reason  it  may  be  introduced  promptly.  The 
tube  is  carried  carefully  in  while  the  borders  of  the  opening  are  held 
apart  with  the  orthodox  retractors,  or  by  means  of  two  blunt  artery  needles 
or  tenaciila,  after  which  it  is  fastened  in  position  by  means  of  tapes  car- 
ried around  the  neck  and  tied  behind  (Fig.  l-27o).     If  the  opening  be  too 


Fig.  1273. — a.  Incision  in  laryngotoray.  b.  Incision  in 
tracheotomy  above  the  isthmus  of  the  thyroid  body, 
c.  Incision  in  tracheotomy  Ijelow  the  istlimus  of  thy- 
roid body,  d,  d.  Sterno-cleido-mastoid  muscles,  e. 
Incision  in  subhyoid  pharyngotomy. 


Ol'KKATIONS   ON    TIIK    XKCK. 


10G5 


sniiill,  it  niiiy  bo  iiicreasod  by  divi.sion  of  tlic  cricoid  cartilage  (crico-laryn- 
(jiitoiini). 

Tracheotomy. — The  operation  of  tracheotomy  consists  in  opening  tlie 
traciiea,  and  is  usually  performed  upon  children,  owing  to  the  small  size  of 
their  crico-thyroid  spaces.  It  is  the  preferable  operation  in  all  instances 
when  the  incision  is  to  be  made  as  far  as  possible  from  a  contagious  local 
disease.  Tracheoiomn  may  he  done  at  three  situations — below  (Fig.  12T;i,  6"), 
above  (i),  and  behind  the  isthmus  of  the  thyroid  gland  ;  the  operation  below 
the  isthmus  is  to  be  preferred. 

2Vie  Anatomical  Points. — The  upper  portion  of  the  trachea  is  quite  super- 
ficial, while  the  lower  is  from  half  an  inch  to  one  inch  below  the  surface, 
depending  ujion  the  shortness  of  the  neck  and  the  obesity  of  the  patient. 
The  lower  portion  recedes,  following  the  curve  of  the  spinal  column.  The 
Tascular  structures  associated  with  this  portion  are  far  more  important  and 
numerous  than  in  other  parts  of  its  course;  the  inferior  thyroid  veins  (Fig. 
1269),  and  their  communications,  pass  in  the 
course  of  the  incision ;  the  arteria  thyroidea 
ima  when  present  runs  along  the  center  of  the 
trachea ;  the  arteria  innominata,  especially  in 
the  child,  runs  obliquely  across  it,  at  the  root  of 
the  neck  from  left  to  right.  The  isthmus  of 
the  thyroid  covers  the  second,  third,  and  often 
the  fourth  rings  of  the  trachea ;  above  it  is  seen 
the  communicating  branch  between  the  superior 
thyroid  veins  (Fig.  1269)  ;  the  thymus  gland, 
which  attains  its  full  size  at  two  years,  en- 
croaches upon  the  space  from  below  upward 
with  each  labored  respiratory  act,  and  may  be 
incised.  It  is  sometimes  difficult  for  the  begin- 
ner, when  surrounded  by  the  turmoil  incident 
to  the  operation,  to  be  certain  of  the  location  of 
the  trachea.  If  the  index  finger  be  inserted  into 
the  wound  the  trachea  will  roll  under  it,  and 
be  felt  ascending  and  descending  beneath  its 
extremity,  and,  when  suflEiciently  isolated,  the 
rings  can  be  seen  and  felt.  Also,  the  inexpe- 
rienced operator  is  likely  to  open  the  trachea  at 
one  side  of  the  median  cut,  making  it  difficult 
to  introduce  the  tube,  causing  it  to  bind  after 
introduction,  and  not  infrequently,  if  the  tis- 
sues overlap  the  cut  before  its  introduction, 
causing  air  to  be  forced  between  their  planes,  creating  local  emphysema.  If 
the  knife  be  inserted  too  far,  the  posterior  wall  of  the  trachea  will  be  divided. 

TJie  Operatio7i  beloiv  the  Isthmus  (Low  Tracheotomy,  Figs.  1272  and 
1273). — Place  the  patient  as  for  laryngotomy,  and,  if  practicable,  employ  an 
anaesthetic.  Support  the  trachea  in  the  median  line,  and  make  an  incision 
extending  from  the  cricoid  cartilage  to  within  half  an  inch  of  the  top  of  the 


Fig.  1273. — Oiierations  on  the 
larynx.  Z.  Ilvoid  bone.  Sch. 
Thyroid  caitilage.  i?.  Cricoid 
cartilage.  T7i.  Outline  of  the 
thyroid  gland.  /.  Subhyoid 
jiharyngotoniy.  //.  Thy- 
I'otomy.  ///.  Infrathyroid 
laryngotomy.  IV.  Cricot- 
oiny.  V.  High  tracheotomy. 
YI.  Low  tracheotomv. 


1066 


OPERATIVE  SURGERY. 


Fig.  1274. — Opening  the  trachea. 


sternum  ;  divide  the  fascia  ou  a  director  ;  cautiously  separate  and  pull  aside 
the  sterno-thyroid  and  sterno-liyoid  muscles,  thus  exposing  the  deeper  cervi- 
cal fascia,  beneath  which  are  located  the  inferior  thyroid  veins  (Fig.  1269), 
supported  by  connective  tissue.     This  fascia  should  be  torn  asunder  by  a 

blunt  instrument,  and  pushed  aside 
along  with  the  veins  and  connective 
tissue  beneath,  which  will  expose  the 
trachea.      The  blunt 
ends  of  two  ordinary 
directors  can  be  util- 
ized   for    separating 
the  fascia,  or  instru- 
ments especially  de- 
vised for  dry  dissec- 
tions   can    be    employed    (Fig.  42). 
Throughout  the  entire  operation  the 
tissues  must  be  drawn  asunder  as  fast 
as  separated,  by  means  of  blunt  hooks 
or  other  form  of  retractors,  to  afford 
ample   exposure   of   each  succeeding 
part.  As  soon  as  the  trachea  is  reached, 
and   all  haemorrhage    checked,  it  is 
seized  by  one  or  two  hooks — the  double 
hook  of  Langenbeck  (Fig.  1271)  being  the  best — drawn  forward  to  near  the 
surface  of  the  wound,  firmly  held,  and  three  or  four  rings  of  the  trachea  divided 
exactly  in  the  median  line  from  above  downward,  or  better  from  below  up- 
ward, by  a  sharp-pointed  knife  (Fig.  1274).     Then  the  dilator  (Fig.  1270)  is 
introduced,  and  the  tube  inserted  and 
confined  in  position  after  the  tracheal 
mucus  and,  blood  have  been  expelled 
(Fig.  1275).      All  incisions,  except  the 
primary  one,  should  be  directed  upward 
to  avoid  the  great  vessels  at  the  root  of 
the  neck.    The  opening  in  the  trachea 
should  be  long  enough  to  admit  the  easy 
expulsion  of  all  false  membranes  and 
foreign  bodies  (an  inch  in  length  is  not 
too  much  for  this  purpose),  and  must 
likewise  readily  admit  the  trachea  tube. 
The  Operation  above  the  Isthmus 
(High  Tracheotomy,  Figs.    1272   and 
1273). — Make  an  incision  of  the  usual 
length,  its  center  corresponding  to  the 
lower  border  of  the  cricoid   cartilage 
(Fig.  1272,  h) ;  divide  and  carefully  separate  the  tissues  as  before ;  the  loop 
of  communication  between  the  superior  thyroid  veins  (Fig.  1269)  must  be 
carefully  drawn  upward,  the  fascial  attachment  between  the  isthmus  and 


Fig.  1275. — Tube  in  position. 


OrKUATlUNS   ON    THE   NECK.  1007 

the  cricoid  cartilage  divided,  the  isthmus  pulled  downward  and  drawn  for- 
wanl  by  a  Ijlunt  hook,  when  the  trachea  can  be  opened  beneath  it  from 
below  upwaril,  and  the  tube  inserted  with  the  same  precautions  as  before. 

Tlie  Operation  through  the  Isthims. — This  method  is  hardly  of  enough 
practical  importance  to  be  entitled  to  a  detailed  consideration,  since  the 
oi)portunitics  afforded  above  and  below  it  will  be  suflicient.  If,  however, 
this  position  be  selected  for  operation,  the  isthmus  should  be  divided  between 
two  ligatures  to  avoid  the  probability  of  troublesome  hajmorrhage.  It  some- 
times hai)pens  that  the  isthmus  is  small  or  too  illy  developed  to  be  trouble- 
some after  its  division  without  ligature. 

Laryngo-tracheotomy. —  In  laryngo-tracheotomy  the  larynx  and  trachea 
are  both  o])cned  by  a  continuous  incision,  which  is  usually  made  to  increase 
the  space,  that  foreign  bodies  and  false  membrane  may  be  removed.  The 
incision  through  the  cricoid  cartilage  and  upper  rings  of  the  trachea  is  then 
secondary  to  the  opening  of  the  larynx.  Before  the  primary  incision  is 
extended,  the  communicating  branches  of  the  superior  thyroid  veins  should 
be  pulled  downward,  the  lower  border  of  the  cricoid  exposed,  the  fascial  con- 
nections of  the  isthmus  to  it  severed,  and  the  isthmus  drawn  downward  and 
forward  as  before,  to  prevent  it  from  being  injured. 

Rapid  Laryngo-tracheotomy  {Saint- Germain). — It  is  sometimes  neces- 
sary to  open  the  larynx  very  (juickly  ;  therefore,  it  is  quite  proper  to  mention 
some  of  the  points  connected  with  this  operation  that  the  surgeon  may  be 
prepared  to  act  with  dispatch  combined  with  caution. 

The  Operation. — With  the  patient  placed  in  the  usual  position  for  tracheal 
operations,  the  surgeon  locates  the  thyroid  and  cricoid  cartilages  and  the 
space  between  them.  Then,  standing  on  the  right  side  of  the  patient,  he 
seizes  and  pushes  forward  the  larynx  by  pressing  the  thumb  on  one  side  and 
index  finger  on  the  other,  between  it  and  the  vertebral  column,  thereby 
making  the  integument  tense.  At  the  same  time  the  index  finger  locates 
the  lower  border  of  the  thyroid  cartilage.  A  straight,  sharp-pointed  bistoury 
is  then  seized  between  the  thumb  and  index  and  middle  fingers,  its  back 
upward,  with  the  middle  finger  so  placed  on  the  blade  that  the  knife  can 
not  penetrate  to  exceed  half  an  inch  in  depth.  While  thus  held,  its  point 
is  quickly  thrust  into  the  larynx  in  the  median  line  at  the  lower  border  of 
the  thyroid  cartilage  and  the  blade  is  carried  downward  with  a  sawing 
motion,  dividing  the  crico-thyroid  membrane,  cricoid  cartilage,  and  one  or 
two  rings  of  the  trachea.  The  opening  through  the  integument  should 
equal  in  length  the  one  made  in  the  larynx  and  trachea.  The  dilator  is 
introduced,  all  bleeding  checked,  and  the  tracheal  tube  placed  in  position. 
Saint-Germain  up  to  1877  had  operated  by  this  method  97  times,  with  but 
three  instances  of  important  haemorrhage,  in  one  of  which  the  posterior  wall 
of  the  tracliea  was  cut. 

Thyrotomy. — Thyrotomy  consists  in  dividing  the  thyroid  cartilage  par- 
tially or  completely  in  the  median  line  (Fig.  1273,  //),  together  with  division 
of  the  thyro-hvoid  and  crico-thyroid  membranes  wdien  additional  room  is  de- 
sired. Thyrotomy  is  performed  for  the  relief  of  laryngeal  obstruction  depen- 
dent upon  various  causes,  when  not  amenable  to  proper  aid  by  simpler  means. 


1068  OPKKATIV'E   SURGJ^KY. 

7%e  Operation. — Place  tlie  piitient  as  for  laryngotomy,  and  after  proper 
anaesthesia  make  in  complete  tlit/rotomy  an  incision  through  tlie  skin  exactly 
in  the  median  line  from  the  lower  border  of  the  hyoid  bone  to  the  upper 
border  of  the  cricoid  cartilage,  extending  it  later  as  circumstances  require  ; 
divide  in  the  median  line  the  fascia  and  contiguous  soft  tissues  down  to  the 
cartilage,  carefully  avoiding  the  crico-thyroid  vessels ;  draw  to  either  side  the 
borders  of  the  divided  soft  parts,  exposing  the  thyroid  cartilage  and  the  upper 
portion  of  the  crico-thyroid  membrane;  incise  the  crico-thyroid  membrane 
transversely  at  the  lower  border  of  the  thyroid  cartilage  for  a  short  distance, 
avoiding  the  crico-thyroid  artery  below  and  the  cricoid  muscles  at  either 
side ;  insert  the  point  of  a  sharp  knife  beneath  the  lower  border  of  the  thyroid 
cartilage  exactly  in  the  median  line  and  cut  upward  sufficiently  for  the  pur- 
pose of  the  operation,  leaving,  if  possible,  the  upper  border  of  the  cartilage 
unsevered  ;  divide  the  upper  border,  if  need  be,  from  witiiin  outward  on  a 
director  with  a  blunt-pointed  knife;  draw  apart  the  respective  borders  of  the 
cartilage,  detaching  sufficiently  the  crico-thyroid  and  thyro-hyoid  membranes 
from  the  cartilage  on  either  side  of  the  larynx  to  permit  of  a  full  view  of  the 
laryngeal  cavity,  after  which  the  special  features  of  the  operation  are  carried 
into  effect. 

T]ie  Precautions. — Divide  to  no  greater  extent  than  necessary  the  car- 
tilage, for,  if  comjalete  division  be  practiced,  it  is  difficult  to  so  adjust  the  parts 
as  to  prevent  thereafter  functional  disturbances  of  the  voice.  It  is  advised 
that  the  cartilages  be  notched  in  front,  also  that  the  sutures  be  passed 
through  the  borders  of  the  cartilages  before  complete  division  so  that  a 
more  accurate  union  of  them  may  be  afterward  secured.  Since  closure  of 
the  rima  glottidis  may  result  from  the  swelling  following  thyrotomy  and 
other  operative  manipulations,  a  tracheotomy  tube  should  be  passed  into  the 
trachea  through  the  lower  limit  of  the  Avonnd  and  retained  as  long  as 
required,  unless  a  tube  is  already  present  below. 

The  Remarks. — A  low  tracheotomy  should  be  performed  before  the  larynx 
is  opened,  when  the  nature  of  the  trouble  bespeaks  free  haemorrhage,  in 
which  case  tamponing  may  be  practiced.  Some  operators  place  the  patient 
in  Trendelenburg's  position,  thus  obviating  the  need  of  the  tampon.  If  the 
cartilage  is  calcified,  bone-cutting  forceps  or  strong  scissors  may  be  required 
to  make  the  separation. 

The  General  Comments. — If  the  tube  be  too  large,  too  loose,  or  too  angu- 
lar, it  is  liable  to  cause  erosions  and  ulcerations  of  the  trachea,  which  may 
extend  through  it  and  implicate  the  vessels  at  the  root  of  the  neck,  causing 
fatal  hsemorrhage.  The  method  of  opening  into  the  trachea  by  a  single 
incision  is  fraught  with  danger,  and  should  not  be  attempted  except  the  neck 
of  the  patient  be  long  and  thin,  and  not  even  then  unless  the  exigencies  of 
the  case  call  for  it.  The  division  of  the  tissues  down  to  the  trachea  by  means 
of  thermo-cautery  or  galvano-cautery  has  many  advocates;  it  is  not,  how- 
ever, a  commendable  practice,  except,  perhaps,  in  local  infections.  The 
searing  of  the  tissues  may  prevent  or  lessen  hemorrhage,  and  likewise 
obviate  the  occurrence  of  infection.  This  is  not  altogether  true,  since  the 
large  veins  which  might  be  otherwise  avoided  are  burned  asunder  and  too 


Oi'KKATlUNS   ON    TllH   NKC'K.  1009 

often  cause  severe  haemorrlia^e,  which  is  not  easily  controlled  because  of 
the  diniculty  of  properly  securing  the  charred  extremities  of  tlie  vessels. 
The  resulting  cicatrix  is  more  distiguring  than  that  following  other  methods. 
It  is  advised  in  bronchotomy  for  dij)htheria  and  acute  alTections  of  the  air 
passages  that  the  tube  be  dispensed  with,  since  it  can  only  prove  a  source  of 
local  irritation,  and  obstructs  the  exit  of  false  membranes  and  the  secretions. 
As  a  substitute,  the  borders  of  the  tracheal  opening  can  be  kept  drawn 
asunder  by  passing  looped  ligatures  through  them  (Martin),  which  are 
united  to  each  other  behind  the  neck  with  this  appliance.  The  patient 
must  be  carefully  N\atched,  since  if  the  head  be  turned  the  opening  may 
become  closed.  If  this  arrangement  prove  troublesome,  an  elliptical  piece 
can  be  removed  from  the  anterior  surface  of  the  trachea.  If  the  piece  to 
be  removed  exceed  a  third  of  the  diameter  of  the  tube,  the  high  operation, 
above  the  isthmus,  would  be  the  one  more  easily  and  quickly  performed, 
and  would  as  well  be  less  dangerous,  as  the  vessels  in  that  situation  are  more 
superficial,  smaller,  and  of  less  significance.  Cutaneous  emphysema,  broncho- 
pneumonia, and  pus  infiltration  of  the  thorax  are  more  liable  to  happen  in 
the  low  than  in  the  high  operation.  It  is  wise  to  confine  the  hands  and 
arms  of  the  patient  with  a  body  bandage  before  operation.  The  median  line 
of  the  neck  should  always  point  toward  the  center  of  the  episternal  notch 
during  operation.  The  trachea  should  be  seized  with  a  hook  and  held  as 
steady  as  possible  during  its  incision  and  the  introduction  of  the  tube.  The 
hissing  entrance  of  air,  coughing,  etc.,  indicate  that  the  lumen  of  the  trachea 
is  entered.  The  use  of  a  probc-poiuted  bistoury  in  the  enlargement  of  the 
tracheal  wound  affords  better  protection  than  the  sharp-pointed  to  the  pos- 
terior wall  of  the  trachea.  Low  tracheotomy  is  indicated  when  it  is  desirable 
to  remove  the  ojiening  as  far  as  possible  from  the  seat  of  local  infection 
above,  also  from  the  seat  of  haemorrhage  in  order  that  the  entrance  to  the 
trachea  of  blood  may  be  more  surely  prevented.  Large  growths  above  call 
for  low  tracheotomy.  In  fact,  the  site  of  the  opening  is  controlled  by  the 
demands  of  the  case.  Careful  scrutiny  during  the  operation  of  low  tracheot- 
omy should  be  exercised  to  observe  and  avoid  the  innominate,  carotid,  and 
median  arteries,  also  the  active  thymus  gland  in  children.  As  silver  tubes 
sometimes  cause  the  characteristic  poisoning  of  that  metal,  it  is  better  to  use 
those  made  of  other  substances.  The  introduction  of  tubes  wrapped  in 
tightly  fitting  iodoform  gauze,  and  their  retention  for  two  days,  is  sometimes 
practiced  for  antiseptic  purposes.  If  the  tube  fits  too  tightly  erosion  of  the 
cartilage  follows.  This  sequel  is  oftener  seen  in  children  because  of  the  too 
limited  space  in  laryngotomy  without  division  of  the  cricoid  cartilage.  A 
tube  can  be  introduced  more  readily  and  safely  if  the  head  be  raised  up 
during  the  act.  The  employment  of  traction  loops  carried  behind  the  neck 
and  tied  together,  or  connected  with  a  small  rubber  band  for  securer  action, 
should  be  discreetly  practiced  to  avoid  the  constriction  incident  to  swollen 
tissues  and  the  tension  arising  from  injudicious  tying  and  persistent  rubber 
traction.  Severe  and  fatal  haemorrhage  is  sometimes  a  part  of  the  history  of 
the  long-continued  use  of  a  badly  fitting  tube,  especially  in  cases  of  low 
tracheotomy.     The  presence  of  granulations  at  the  anterior  and  posterior 


1070  OPKKATIVK   Sl'IUiEIiV. 

parts  of  the  tracheal  wound  often  render  the  incautious  removal  of  the 
instrument  painful  and  dangerous  because  of  their  obstruction  to  the 
entrance  of  air. 

The  After-treatment. — The  tube  should  be  kept  in  place  until  the  cause 
for  the  operation  is  removed,  after  which  the  sooner  it  is  dispensed  with  the 
better.  However,  the  final  removal  should  be  approached  in  easy  stages  so 
regulated  as  not  to  expose  the  patient  to  the  dangers  and  discomforts  of 
obstructive  symptoms  that  are  so  often  a  part  of  the  history  of  a  case,  espe- 
cially one  of  a  jDrolonged  or  paralytic  nature,  in  withdrawal  of  the  tube. 
Cleanliness  of  the  wound,  absence  of  dust,  and  the  utilization  of  moistened 
and  medicated  air,  etc.,  are  the  essential  features  of  treatment.  The  assur- 
ance that  the  tube  is  open  and  securely  fixed  in  the  trachea  during  the 
danger  period  requires  constant  attention,  especially  in  children,  who  by  rest- 
lessness or  non-restraint  may  displace  or  remove  it. 

Tlie  Results. — But  few  perish  from  the  direct  results  of  the  preceding 
operations.  Bronchitis,  infection  pneumonia,  haemorrhage  from  ulceration 
through  the  trachea  caused  by  the  tube,  and  primary  hwmorrliage  from 
wounds  of  the  vessels  at  the  root  of  the  neck,  or  from  an  abnormally  large 
crico-thyroid  artery,  constitute  the  leading  causes  of  death  directly  due  to 
the  operation.  A  deeply  cyanosed  patient,  in  the  tonic  stage  of  anaesthesia, 
may  die,  especially  if  blood  be  allowed  to  enter  the  tracheal  opening.  In 
this  contingency  the  blood  must  be  removed  at  once,  and  artificial  respira- 
tion be  resorted  to.  Tracheotomy  in  diphtheria  is  undoubtedly  a  most 
feasible  operation,  and  should  be  performed  early,  before  cyanosis  is  well 
established.  Monti,  of  Vienna,  in  his  recent  work  on  Croup  and  Diphthe- 
ria, records  12,T36  tracheotomies  for  diphtheria  alone,  with  3,409  recoveries, 
or  nearly  28  per  cent.  It  is  estimated  that  25  per  cent  of  these  cases  have 
been  saved  which  otherwise  would  have  died.  About  27.5  per  cent  perish 
from  bronchotomy  for  the  removal  of  foreign  bodies.  The  use  of  antitoxine 
and  the  employment  of  intubation  have  rendered  in  this  country  the  opera- 
tion of  tracheotomy  comparatively  infrequent.  The  beneficence  of  this 
change  in  both  sentimental  and  medical  aspects  is  of  pronounced  importance. 
The  employment  of  antitoxine  at  the  proper  period,  while  not  always  pre- 
venting the  need  of  tracheotomy,  lessens  the  fatality  when  required. 

Subhyoid  Pliaryngotomy. — This  operation  is  practiced  for  the  removal 
of  foreign  bodies  and  morbid  growths  situated  high  up  in  the  air  passage, 
and  for  the  relief  of  abscesses  at  the  base  of  the  epiglottis. 

The  Operation. — Place  the  patient  as  for  laryngotomy;  administer  an 
anaesthetic,  and  make  an  incision  an  inch  and  a  half  or  two  inches  in  length 
transversely  along  the  lower  border  of  the  h3-oid  bone,  with  its  center  in  the 
median  line  (Fig.  1272,  e).  The  integument,  fascia,  platysma,  and  the  inner 
portions  of  the  sterno-hyoid  muscles,  and  finally  of  the  thyro-hyoid  muscles, 
are  divided  on  a  director.  The  only  vessel  contiguous  to  the  incision  is  the 
superior  thyroid  artery,  which  runs  along  the  upper  border  of  the  thyroid 
cartilage  parallel  with  the  incision.  The  thyro-hyoid  membrane  is  now 
exposed  and  opened  by  a  sharp-pointed  knife  carried  obliquely  upward. 
The  mucous  membrane  is  divided  through  the  glosso-epiglottic  fossa  aided 


urHKATlUNS   ON    Till';    NKCK. 


KlTl 


by  the  fingers  introduced  into  the  mouth.  If  the  greater  cornnii  of  the 
hyoid  bone  be  severed  ;il»out  three  fourths  of  an  inch  from  the  extremities, 
access  to  the  phai-ynx  will  be  facilitated.  Divided  vessels  sIhju Id  he  promptly 
tied  to  prevent  entrance 

of  blood  to  the  trachea.  -.^iE--i==::_^ 

As  soon  as  the  thyro- 
hyoid membrane  is  cut, 
the  epiglottis  will  pro- 
ject througli  the  ojien- 
ing,  and  must  be  drawn 
aside,  when  the  tumor 
will  be  exposed  to  view 
(Fig.  1270).  After  the 
removal  of  the  growth, 
the  wound  is  closed  and 
dressed  antiseptically. 
The  majority  of  the  con- 
ditions calling  for  this 
operation  can  be  satisfac- 
torily treated  through 
the  mouth. 

The  Prognosis. — The 
operation   itself    implies 
no  unusual  danger  to 
the  patient. 

A  preliminary  tra- 
cheotomy should   be 
performed   if   undue 
haemorrhage    is    an- 
ticipated, as  in  the  ex- 
tirpation  of   a    vascular 
growth,     supplemented, 
perhaps,  by  plugging  the 
trachea    in    urgent    in- 
stances.  The  Trendelen- 
burg posture  will  atiford 
great  advantage. 

Intubation  of  the  Larynx. — Boicchut,  of  Paris,  conceived  the  idea,  and 
O'Dwyer,  of  New  York,  by  indefatigable  and  patient  labor  achieved  the  imper- 
ishable distinction  of  establishing  its  utility  upon  an  enduring  basis.  For- 
eign bodies  in  the  larynx  and  diseased  processes  contiguous  to  it,  causing 
obstructive  dyspna?a,  are,  as  a  rule,  better  treated  by  tracheotomy  than  by 
intubation.  Chronic  stenosis  of  the  larynx  from  tubercle,  syphilis,  and  other 
chronic  states  of  an  inflammatory  nature  can  be  promptly  and  often  effec- 
tually treated  by  intubation.  However,  the  chief  importance  of  the  measure 
rests  in  affording  prompt  relief  in  impending  suffocation  from  membranous 
obstruction  (Fig.  1277).    The  following  is  a  description  of  the  apparatus : 


Fig.  1276. — Tlie  operation  of  subhyoid  pliarvngotomy.  a. 
Ilyoid  bone  with  thyro-hyoid  membrane  attached,  b. 
Sterno-hyoid  and  omo-hyoid  muscles,  c.  Extremity 
of  greater  cornu.  d.  ?]ntrance  to  larynx,  e.  Superior 
laryngeal  nerve.  /.  Epiglottis,  g.  Platysma.  h.  Thy- 
roid notch. 


1U72 


OPERATIVE   SURGERY. 


"  The  numbers  on  the  scale  (Fig.  12TT,  e)  indicate  the  years  for  which  the 
corresponding  tubes  are  suira])le.  For  instance,  the  smallest  tube  when 
applied  to  the  scale  will  reach  to  the  first  line,  marked  1,  and  is  intended  to 


Fig.  1277. — The  O'Dwyer  apparatus  for  intubation. 

a.  Extractor,  b.  Introdnctor  with  oljturator  attached,  c.  Obturator  detached,  d.  Tubes, 
assorted  sizes,  one  with  obturator  in  place,  e.  Scale  indicating  size  of  tube  mouth 
gag  (Figs.  4  and  1278),  also  the  O'Dwver  gag.     Tongue  depressor  may  be  required. 

be  used  up  to  the  age  of  twelve  or  fifteen  months ;  the  size  marked  2  is 
suitable  for  the  next  year,  3  and  4  for  these  years,  and  so  on.  When  the 
proper  tube  is  selected  for  the  case  to  be  operated  on,  a  loop  of  fine  thread 
about  fourteen  inches  in  length  is  fixed  through  the  small  hole  near  its  ante- 
rior angle,  and  left  long  enough  to  hang  out  of  the  mouth  after  the  intro- 
duction of  the  tube,  its  object  being  to  withdraw  the  tube  should  it  be  found 
to  have  passed  into  the  cesophagus  instead  of  the  larynx. 

"  The  obturator  (Fig.  1'2TT,  c)  is  then  fastened  tightly  to  the  introdnctor 
(Fig.  1277,  b),  to  prevent  the  possibility  of  its  rotating  while  being  inserted, 
and  passed  into  the  tube. 

"  The  following  is  the  method  of  iyitrodncing  the  tube,  which  is  done 
without  the  use  of  an  anaesthetic:  The  child,  with  the  arms  confined,  is  held 
upright  in  the  arms  of  a  nurse,  and  the  gag  is  (Fig.  1278)  inserted  in  the 
left  angle  of  the  mouth,  well  back  between  the  teeth,  and  widely  opened ; 
an  assistant  holds  the  head,  thrown  somewhat  backward,  while  the  operator, 
standing  in  front,  inserts  the  index  finger  of  the  left  hand  backward  and 
downward  into  the  throat,  elevates  the  epiglottis,  draws  the  base  of  the 
tongue  forward,  and  at  the  same  time  directs  the  tube  into  the  larynx  (Fig. 
1279). 

"  The  handle  of  the  introdnctor  (Fig.  1277,  h)  is  held  close  to  the  patient's 
chest  in  the  beginning  of  the  operation,  and  rapidly  elevated  so  that  the  tube 
approaches  the  glottis  at  an  acute  angle,  and  passing  under  the  end  of  the 


OI'KKATIONS   OX    TIIK    NKCK. 


107;^ 


finger  (Fig.  I'-iSO)  is  tlieii  })iished  do\vu\Viu\l  in  the  median  line,  witliout 
using  force,  and  pressed  into  place  by  the  finger  and  the  tube  detached  (Fig. 
r^81).  The  joint  in  the  shank  of  the  obturator  is  for  the  purpose  of  facili- 
tating this  part  of  the  operation.  As  soon  as  the  obturator  is  removed,  and 
it  is  ascertained  that  the  tube  is  in  the  larynx,  the  thread  is  withdrawn,  but 
at  the  same  time  the  finger  is  kept  in  contact  with  the  tube  to  prevent  its 
being  also  witlulrawn  (Fig.  r^8::2). 

"  It  is  important  that  the  attempt  at  introduction  be  made  quickly,  as 
respiration  is  practically  suspended  from  the 
time  that  the  linger  enters  the  larynx  until 
the  obturator  is  removed.  It  is  therefore, 
under  the  circumstances,  much  safer  to  make 
several  abortive  attempts  than  one  prolonged 
effort,  even  if  successful. 

"For  the  purpose  of  removal,  the  patient 


Fig.  1278.— The  operation  of  intubation,  method  of  introducing  the  tube.     The  respiratory 
tract  of  operator  protected  from  infection  by  mouth  siiield.  and  clothing  by  a  gown. 

is  held  in  a  similar  position,  except  that  the  head  is  not  inclined  backward, 
or  very  slightly  so,  and  the  extractor  (Fig.  1277,  a)  is  passed  cautiously  and 
lightly  into  the  tube  guided  by  the  index  finger  of  the  left  hand,  which  also 
fixes  the  epiglottis,  and  is  brought  in  contact  with  the  head  of  the  tube. 
Firm  pressure  with  the  thumb  is  then  made  on  the  lever,  above  the  handle, 
while  the  tube  is  being  withdrawn.  If  secondary  dyspucea  supervenes  at 
any  time,  the  tube  should  be  removed  and  a  larger  one  substituted." 


10  7i 


OPERATIVE  SURGERY. 


The  late  Dr.  O'Dwyer  recommended  that  preliminary  practice  in  the 
introduction  and  removal  of  the  tube,  and  touching  of  the  parts,  be  had  upon 
the  cadaver  when  possible.     The  removal  of  the  tube  is  more  difficult  than 

the  introduction,  on  ac- 
count of  the  trouble  of 
inserting  the  blades  of 
the  extractor  into  the 
open  upper  end  of  the 
tube  while  more  or  less 
completely  hidden  from 
view  by  the  natural  posi- 
tion of  the  surrounding 
soft  parts.  This  part  of 
the  operation  becomes 
especially  troublesome 
when  the  patient  offers 
any  opposition  to  the  at- 
tempt, and  it  may  be- 
come necessary  under 
these  circumstances  to  ad- 
minister an  anaesthetic 
before  the  tube  can  be 
safely  removed.  The  oc- 
be  met  bv  holdins:  the  finder  in 


Fig.  1279. — The  operation  of  intubation.  Elevating  epi- 
glottis and  drawing  tongue  forward  with  finger,  direct- 
ing tube  into  larynx.    String  in  tube. 


currence  of  spasm  during  this  time  may 
place  until  the  irritation  subsides. 

Tlie  Precautions. — It  is  often  wise  in  intubation  to  prepare  for  trache- 
otomy (Fig.  1270),  as  efforts  at 
intubation  may  not  succeed. 
Do  not  remove  the  loop  until 
quiet  breathing  has  continued 
for  half  an  hour  or  so,  and  do 
not  permit  the  patient  to  grasp 
it.  The  introduction  of  the 
tube  is  rarely  attended  with 
asphyxia  due  to  detachment 
downward  of  the  membrane, 
and  then,  if  the  patient  be 
caused  to  cough  as  the  tube  is 
quickly  withdrawn,  the  mem- 
brane is  usually  expelled.  Fail- 
ing in  this,  tracheotomy  for- 
ceps may  be  tried  for  removal 
of  the  membrane  which,  if  in- 
effective, is  followed  at  once  by 
tracheotomy.      Three  or  four 

per  cent  only  require  the  latter  measure  of  relief.     The  tube  may  be  passed 
into  the  oesophagus  and  possibly  enter  the  trachea.     The  evidences  of  par- 


FlG. 


1280. — The  operation  of  intubation, 
passing  under  end  of  finger. 


Tube 


OPERATIONS   ON    TllH    NKCK. 


10 


<o 


Fig.  1281. — The  operation  of  intubation.   The  tube  pressed 
into  i)lace  with  the  finger  and  detached  from  obturator. 


tially  (Ictaclu'd    iiu'iuljiaiic  in  the  traclioa  call  for  prompt  removal  of  the 
tube.     Inversion  of  the  i)atient  and  striking  of  the  body  by  the  attendants 

may  cause  the  tube  to  be 
expellqd  along  with  the 
obstructing  membrane 
and  rescue  the  patient 
without  the  dangers  of 
delay.  The  not  infre- 
quent occurrence  of  se- 
vere and  perhaps  fatal 
dyspncea,  following  re- 
moval of  the  tube,  enjoins 
close  attention  to  the  pa- 
tient for  an  hour  or  so 
thereafter. 

The  Remarks. — In  the 
adult  the  tube  can  be  in- 
troduced by  aid  of  a  mir- 
ror, especially  when  the 
throat  is  accustomed  to 
the  use.  It  is  wise  for  the 
operator  to  give  some  little  amount  of  time  to  practicing  in  introducing 
the  tube.  The  extracting  of  the  tube  from  the  clinched  hand  will  offer  in  a 
degree  the  needed  opportunity  for  this  kind  of  practice.  Should  the  tube 
happen  to  slip  below  the  vocal 
cords  it  will  no  doubt  be  ar- 
rested by  the  cricoid  cartilage 
and  only  by  division  of  the  lat- 
ter can  the  tube  be  withdrawn 
from  below. 

Tlie     After  -  treatment.  — 
Quiet,  support,  and  cleanliness 
are  indicated.     Caret/ vrnd  Cas- 
seJherry  have  recorded 
portant  fact  that 
with     the     head 
lower    than     the 
shoulders       food 
can  be  swallowed 
quite  readily  with 
the  tube  in  place 
without        much 
trouble.      Highly 
nutritious      fluid 
foods    are     com- 
monly employed  in  these  cases.     Usually  the  tube  is  removed  in  four  or  five 
days  and  not  reintroduced  thereafter  without  special  indications. 
74 


Fig.  1282. — The  operation  of  intubation.     Tlie  tube 
held  in  place  by  finger  while  string  is  withdrawn. 


1076  OPERATIVE  SURGERY. 

TJie  Results. — McNaughton  and  Maddern  reported  5,546  cases  of  intu- 
bation with  69.5  per  cent  mortality  without  the  use  of  antitoxine.  Five 
hundred  and  thirty-three  cases  with  the  use  of  antitoxine  gave  25.9  per  cent 
mortality.     With  the  use  of  antitoxine — 


Cases. 

Recoveries. 

Brown  reports 

1,445 

72 
30 

647 

Ranke  reports 

553 

McNaughton  reports              

28 

O'Dwver  reports 

10 

Waxhani  reports  543  cases  of  intubation  in  private  practice  with  39.29 
per  cent  recoveries. 

It  is  quite  apparent  that  intubation  is  followed  by  a  higher  rate  of  recov- 
ery than  is  tracheotomy,  and  that  the  administration  of  antitoxine  increases 
the  efficiency  of  intubation  in  an  astonishing  degree. 

Foreign  Bodies  in  the  Air  Passages. — Foreign  bodies  invade  the  air  pas- 
sages, and  in  many  instances  cause  alarming  symptoms  followed  by  a  rapid 
and  fatal  outcome.  The  larynx,  trachea,  and  bronchi  are  the  common  sites 
of  invasion,  and  demand  the  exercise  of  discreet  though  prompt  and  efficient 
action  for  relief.  A  knowledge  of  the  nature  of  the  foreign  body  is  of  great 
importance,  as  bearing  on  the  ease  of  removal  and  the  kind  of  tissue  changes 
induced  by  its  presence.  The  surroundings  of  the  patient  have  much  to  do 
with  determining  the  nature  of  these  bodies.  However,  corn,  beans,  various 
seeds,  and  small  toys  make  up  a  large  proportion  of  these  offending  agents. 
Seeds  increase  in  size  naturally  from  the  absorption  of  moisture,  and  become 
therefore  more  difficult  of  removal  as  time  advances.  Organic  agents  of 
infective  character  are  especially  dangerous  because  of  the  tissue  changes 
which  they  incite.  Inorganic  substances  are  the  least  objectionable  unless 
endowed  with  some  special  destructive  nature.  The  employment  of  the 
X  rays  are  especially  serviceable  in  determining  the  location  and  nature  of 
the  object. 

The  invasion  of  the  larynx  by  a  foreign  body,  attended  with  symptoms 
of  pronounced  character,  calls  for  a  prompt  examination  of  the  throat  and 
larynx  with  the  finger,  and  unless  relief  be  thus  promptly  afforded,  laryn- 
gotomy  in  the  adult  and  tracheotomy  in  the  child  should  be  performed  at 
once.  When  the  symptoms  are  not  urgent,  a  more  deliberate  course  can  be 
followed,  fortified  by  the  knowledge  gained  by  the  use  of  the  laryngoscope, 
fluoroscope,  and  other  methods  of  inquiry.  And,  too,  the  removal  may  be 
deliberately  conducted  with  approved  instruments,  and  operative  procedures 
directed  to  opening  the  larynx  above,  through,  or  below  the  thyroid  carti- 
lage, according  to  the  situation  of  the  foreign  body,  utilizing  by  this  route 
the  best  channel  for  removal. 

The  invasion  of  the  trnchea  by  a  foreign  body  calls  for  a  prompt  low 
tracheotomy,  which  should  be  done,  if  possible,  before  the  fixation  of  the 
foreign  body  in  a  bronchus  takes  place.  The  opening  should  be  free  to 
admit  of  prompt  escape  of  the  offending  agent  with  the  act  of  coughing. 
If  the  foreign  body  have  become  fixed  already,  dislodgment  should  be  at- 


OPERATIONS   ON   TIIK    Nl-X'K.  1077 

tempted  with  a  probe  or  feather,  while  tiie  tracheal  opening'  is  liehl  widely 
apart  to  facilitate  the  escape.  Inversion  of  the  patient,  thunii)ing  on  the 
back,  etc.,  are  practiced  after  tracheotomij  is  performed.  In  the  interval  of 
the  attempts  at  removal  the  borders  of  the  tracheal  wound  should  be  held 
widely  apart  with  traction  sutures  carried  through  each  Ijorder  around  the 
neck  and  tied  behind. 

The  invasion  of  a  bronchus  by,  and  linal  lixation  there,  of  a  foreign  body, 
while  not  immediately  dangerous,  exposes  the  patient  to  many  problematical 
contingencies  of  a  fatal  nature.  The  foreign  body  may  block  the  entire 
right  or  left  bronchus,  or  one  or  more  subdivisions  of  tlie  same,  singly  or 
simultaneously,  according  to  its  size.  The  right  bronchus  is  involved  more 
frequently  than  the  left,  the  proportion  being  three  of  the  former  to  two  of 
the  latter. 

The  Treatment. — In  the  instance  of  seed  impaction,  a  policy  of  conser- 
vatism is  usually  the  wiser  one. 

Inversion  and  thumping  ou  the  back  can  be  practiced  without  trache- 
otomy when  the  object  is  known  to  be  of  so  small  a  size  as  to  readily  escape 
through  the  rima  glottidis.  However,  if  the  object  be  a  large  one  or  of 
uncertain  size,  or  the  case  one  which  has  been  attended  already  by  violent 
efforts  at  expulsion,  then  tracheotomy  and  wide  separation  of  the  tracheal 
opening  should  always  precede  any  effort  at  dislodgnieut. 

Direct  dislodgment  is  practiced  with  forceps,  probes,  bent  wire,  blunt 
hooks,  suction  by  a  rubber  tube  attached  to  Bigelow's  litholopaxy  pump, 
corkscrew  apparatus,  etc.  The  stereotyped  and  extemporized  implements 
and  means  for  extraction  are  numerous,  but  favorable  outcome  does  not 
keep  pace  with  ingenuous  though  often  unwise  instrumentation.  In  gen- 
eral terms  the  following  plan  of  interference  is  commended  :  Locate  the 
site  of  the  impacted  obstruction  by  auscultation,  etc. ;  perform  a  free,  low 
tracheotomy,  and  hold  the  borders  of  the  tracheal  wound  widely  asunder 
with  traction  sutures ;  introduce  a  flexible  probe,  and  locate  the  obstruction 
and  dislodge  it  if  possible;  failing  in  this,  try  forceps  of  proper  size  and 
shape,  or  a  wire  with  a  hooked  extremity,  or  fine  silver  wire  looped  and 
passed  beyond  the  obstructing  agent  and  withdrawn.  The  patient  should 
be  under  an  anesthetic  during  the  attempts,  otherwise  the  spasmodic  cough, 
due  to  the  irritation  of  the  manipulation,  will  defeat  careful  effort  and  per- 
haps cause  avoidable  disaster.  It  may  be  advisable  to  open  the  thorax  pos- 
teriorly to  effect  relief  (page  1046). 

The  Comments. — When  tracheotomy  is  followed  by  entire  relief  from 
dyspnoea,  the  foreign  body  is  either  in  the  larynx  or  occupies  a  small  tube. 
The  presence  of  a  foreign  body  in  the  bronchus  is  not  an  absolute  indication 
for  operation,  as  circumstances  may  contraindicate  it.  When  the  obstruc- 
tion can  be  located,  a  low  tracheotomy  is  justifiable  with  brief,  cautious 
attempts  at  extraction. 

The  question  of  tracheotomy  will  depend  largely  upon  the  form,  size, 
and  character  of  the  foreign  body.  Xot  more  than  three  attempts  of  a 
minute  each  should  be  employed  with  forceps  to  remove  a  foreign  body 
(Gross). 


1078  OPERATIVE  SURGERY. 

"  Low  tracheotomy  is  advisable  when  the  presence  of  a  foreign  body  is 
certain  ;  it  adds  but  little  to  the  risk  and  affords  easier  escape  for  the  object, 
even  when  extraction  is  not  feasible. 

"  Subsequent  dangers  arise  from  severe  and  prolonged  instrumentation, 
not  from  tracheotomy.  Voluntary  expulsion  is  more  probable  after  than 
before  tracheotomy. 

"  The  risks  of  thoracotomy  and  bronchotomy,  following  unsuccessful  tra- 
cheotomy, are  greater  than  the  dangers  incurred  by  permitting  the  foreign 
body  to  remain"  (Willard). 

The  Results. —  Voluntary  expulsion  is  not  an  uncommon  occurrence, 
happening  within  a  few  hours,  or  after  weeks'  and  even  years'  dehiy.  Nearly 
90  per  cent  will  recover  without  operative  interference  (Weist). 

"  When  a  foreign  body  becomes  impacted  in  the  bronchus,  extraction 
is  an  impossibility  in  78  per  cent  of  the  cases  even  after  tracheotomy" 
(Willard). 

The  employment  of  instruments  increases  the  death  rate  from  pneu- 
monia 12  per  cent.  Smith  reports  in  1,G00  cases  a  TO-per-cent  rate  of 
recovery  in  the  non- operative  and  76  per  cent  in  operative  cases.  Dunham 
reports  50  per  cent  recoveries  in  non-operative  and  77  per  cent  in  operative 
cases. 

Guyon  and  Diuiluim  in  1,G74  cases  report  70  per  cent  recoveries  in  non- 
operative  and  75  per  cent  in  operative  cases.  About  10  per  cent  die  from 
the  operation  only. 

Laryngectomy. — Laryngectomy  is  a  serious  operation  and  is  not  practiced 
except  for  the  cure  of  malignant  disease.  It  consists  in  the  removal  of  a 
part  or  the  whole  of  the  larynx,  and  is  classified,  therefore,  as  the  complete 
and  incomplete  varieties. 

Complete  Laryngectomy.— If  the  neck  be  not  too  short  for  the  purpose, 
as  may  be  the  case  in  emphysematous  patients,  a  preliminary  tracheotomy 
should  be  performed  several  days  in  advance  of  the  major  operation,  to 
accustom  the  pulmonary  tissues  of  the  patient  the  sooner  to  the  influences 
of  the  abnormal  respiratory  channel.  If  the  neck  be  too  short  for  the  utiliza- 
tion of  this  preparatory  step,  the  cannula  may  be  introduced  during  the  course 
of  the  operation  (Kocher).  After  the  patient  is  ana?sthetized,  the  trachea  should 
be  plugged  by  the  use  of  the  Trendelenburg  or  the  llahn  sponge  tampon  can- 
nula (Figs.  1284  and  1285),  being  certain  that  the  rubber  tampon  is  new  and 
that  it  be  slowly  distended  into  the  proper  position.  The  ordinary  cannula, 
supplemented  by  sponge  packing,  is  employed  with  entire  satisfaction  by 
many  surgeons. 

The  Operation  (Kocher). — Place  the  patient  on  the  back  witli  the  shoul- 
ders raised  and  the  head  extended  over  a  padded  bottle  or  sandbag ;  make 
an  incision  in  the  median  line  from  the  hyoid  bone  downward  to  a  point  an 
inch  and  a  quarter  below  the  cricoid  cartilage,  exposing  the  thyroid  and 
cricoid  cartilages  and  the  upper  border  of  the  isthmus  of  the  thyroid  body ; 
divide  the  suspensory  ligament  of  the  isthmus  at  the  lower  border  of  the  cri- 
coid ;  separate  the  isthmus  and  its  associated  transverse  veins  from  the  tra- 
chea and  push  them  downward  with  a  blunt  dissector ;  divide  the  cricoid 


()1*KI;A'1'1()NS    on    'IMIK    NKCK.  H)-ij 

and  upper  riugs  of  the  trache;i  iu  liie  mediiin  line,  forcing  tlie  istluiius 
downward  and  even  dividing  it  between  two  ligatures  in  the  median  line  if 
sufficient  room  can  not  be  otherwise  gained  ;  introduce  the  tampon  cannula  ; 
make  a  transverse  incision  through  the  skin  and  fascia  along  the  hyoid 
bone,  ligaturing  the  anterior  jugular  veins;  divide  the  sterno-hyoid,  the 
omo-hvoiil,  and  thyro-hyoid  muscles  close  to  the  hyoid  bone,  at  their  inser- 
tions; draw  the  hyoid  bone  up  with  a  strong,  sharj)  hook  ;  divide  transversely 
the  portion  of  the  thyro-hyoid  membrane  attached  to  the  middle  part  of  the 
hyoid  bone ;  divide  also  the  subjacent  mucous  membrane  and  seize  the  epi- 
glottis at  its  upper  part  with  a  sharp  hook  and  draw  it  forward  ;  slit  the 
epiglottis  medianly  if  healthy,  if  unhealthy  cut  round  it  beyond  the  diseased 
tissue;  split  the  thyroid  cartilage  at  the  middle  downward  to  the  tracheal 
wound ;  arrest  htemorrhage  at  the  wound  edges  and  paint  them  with  a  ten- 
per-cent  solution  of  cocain  to  obviate  the  coughing  and  swallowing  reflexes; 
define  the  limits  of  the  new  growth  and  divide  the  tissues  beyond  them ; 
divide  the  mucous  membrane  with  the  thermo-cautery.  If  the  whole  larynx 
be  diseased,  divide  the  mucous  membrane  along  the  epiglottis,  arytenoid  car- 
tilages, the  larynx  or  trachea,  to  below  the  tumor ;  expose  the  outer  surface 
of  the  larynx,  preserving  the  muscles  in  so  far  as  is  consistent  with  the 
removal  of  diseased  tissue  ;  expose  the  cartilages  and  remove  them  partially 
or  entirel}',  according  to  the  extent  of  the  disease ;  retain  the  healthy  and 
movable  mucous  membranes  at  the  posterior  surface  of  the  cricoid  cartilage ; 
continue  downward  the  dissection  to  the  lower  limit  of  the  disease,  dividing 
the  healthy  cricoid  or  trachea  transversely  ;  sew  upward  as  far  as  possible  the 
anterior  wall  of  the  oesophagus  and  pharynx  to  re-establish  the  septum 
between  the  respiratory  and  alimentary  passages. 

The  After-treatment. — Substitute  a  simple  cannula  for  the  tampon  can- 
nula. Introduce  no  sutures,  but  stuff  the  cavity  with  carbolic  gauze  which 
is  changed  every  two  hours.  Feed  the  patient  through  an  oesophageal  tube 
and  get  him  out  of  bed  as  soon  as  possible. 

7 he  Results. — But  1  case  in  12  died  from  this  plan  of  operation. 

Treves's  Method. — The  following  succinct  plan  of  procedure  is  intro- 
duced from  Treves's  Operative  Surgery: 

"  The  Operation. — The  patient  lies  upon  the  back,  close  to  the  right 
border  of  the  table.  The  shoulders  are  raised,  and  the  head  is  well  extended 
over  a  hard  cushion  or  sandbag.  The  surgeon  stands  on  the  patient's  right. 
The  chief  assistant  takes  his  place  at  the  head  of  the  couch,  and  close 
to  the  surgeon's  left.  An  incision  is  made  in  the  median  line  from  the 
center  of  the  thyro-hyoid  membrane  to  the  second  or  third  ring  of  the 
trachea.  At  the  upper  end  of  this  incision  a  transverse  cut  is  made  which 
is  carried  outward  on  either  side  sufficiently  far  to  reach  the  sterno-mastoid 
muscles. 

"The  flaps  thus  marked  out  are  turned  back.  Some  division  of  the 
fibers  of  the  sterno-mastoid  muscles  may  be  necessary.  The  vertical  incision 
should  go  down  to  the  thyroid  and  cricoid  cartilages  and  the  trachea. 

"  The  superior  thyroid  arteries  may,  if  thought  fit,  be  dealt  with  at  this 
stage.     They  should  be  secured  by  two  ligatures,  and  then  divided  between 


I08(t  opp:rative  surgkuy. 

them.     The  vessels  would  be  sought  for  at  the  })Osterior  margin  of  the  thyro- 
hyoid muscle,  close  to  the  upper  border  of  the  thyroid  cartilage. 

"  The  inferior  thyroid  arteries  may  be  exposed  and  dealt  with  in  the  same 
manner  as  they  turn  forward  at  the  lower  margin  of  the  larynx.  They  should 
be  sought  for  beneath  the  posterior  edge  of  the  sterno-thyroid  muscle. 

"  The  fascia  having  been  well  divided  in  the  middle  line,  a  broad  perios- 
teal elevator  or  a  rugine  is  introduced,  and  by  means  of  it  the  soft  parts  can 
be  separated  from  the  laryngeal  cartilages  without  employing  the  knife. 

"  The  crico-thyroid,  sterno-thyroid,  and  thyro-hyoid  muscles  are  detached 
on  one  side,  and  are,  together  with  the  other  soft  parts,  held  with  a  retractor 
while  the  larynx  is  drawn  over  to  the  other  side  by  means  of  a  sharp  double 
hook.  The  attachment  of  the  inferior  constrictor  muscle  to  the  thyroid 
cartilage  can  now  be  severed,  partly  by  detachment  with  the  elevator  or 
rugine,  and  partly  by  cutting  it  with  curved,  bluut-pointed  scissors,  which 
are  kept  very  close  to  the  cartilage.  The  larynx  is  now  pulled  forward  as 
well  as  to  the  opposite  side,  and  the  tissues  are  divided  about  the  gap  which 
intervenes  between  the  cut  and  now  separated  ends  of  the  superior  thyroid 
artery.  The  superior  laryngeal  nerve  is  also  now  divided.  The  thyroid 
gland  is  pushed  aside  with  the  soft  parts. 

"  If  the  larynx  be  now  well  drawn  over  to  the  other  side,  the  other  half 
of  the  organ  cau  be  stripped  of  its  coverings  in  precisely  the  same  manner. 

"  The  next  step  is  to  divide  the  thyro-hyoid  ligaments  and  membrane, 
and  to  cut  the  extralaryngeal  connections  of  the  epiglottis.  This  structure 
may  be  convenientl}'  drawn  forward  while  its  attachments  are  being  freed. 

"  The  entire  larynx  is  now  pulled  forward  by  means  of  sharp  hooks 
introduced  into  its  upjaer  part,  and  the  organ  is  separated  from  its  remaining 
connections  with  the  pharynx  and  oesophagus — at  first  laterally,  and  then 
from  above  downward. 

"  If  proper  care  be  taken,  the  oesophagus  should  be  nowhere  '  button- 
holed.' Si^ecial  care  is  required  to  separate  the  cricoid  cartilage  from  the 
commencement  of  the  gullet. 

"  The  trachea  is  now  secured  (unless  already  adherent)  by  means  of  two 
ligatures,  which  are  held  by  an  assistant,  and  the  excision  is  completed  by 
dividing  the  membrane  between  the  cricoid  cartilage  and  the  trachea  from 
behind  forward. 

"  One  or  more  rings  of  the  trachea  may  be  removed  at  the  same  time  if 
it  be  considered  necessary. 

"  The  upper  end  of  the  divided  trachea,  which  has  been  prevented  from 
slipping  down  by  the  two  ligatures,  is  now"  secured  to  the  integument  by 
several  points  of  interrupted  suture. 

"  Three  or  four  deep  sutures  of  silver  wire  are  passed  beneath  the  upper- 
most ring,  and  are  made  to  attach  the  windpipe  securely  to  the  skin;  a 
further  series  of  fine  superficial  sutures  unite  the  mucous  membrane  of  the 
trachea  to  the  cut  margin  of  the  skin. 

"  The  bleeding  throughout  the  operation  will  be  free,  and  each  small 
vessel  should  be  ligatured  as  soon  as  it  is  divided.  The  limited  space  does 
not  favor  the  use  of  many  pressure  forceps." 


OI'KRA'IIUNS   UN    TIIK   NECK.  lOgl 

It  often  /ifippois  that  in  addition  to  the  larynx  tlie  liyoid  bone,  base  of 
the  ton^^iie,  })harvn.\,  and  a;.soi)hagus  are  involved  in  a  malignant  growtii. 
If  operation  be  atteni{)tcd,  under  tiiese  circumstances,  the  first  step  is  to  intro- 
duce the  tampon  cannula  of  Trendelenburg,  or  a  substitute,  through  which 
the  anaesthetic  is  administered.  Then  make  a  transverse  incision  through 
the  skin  from  the  inner  edge  of  one  sterno-mastoid  muscle  to  the  other, 
passing  half  au  inch  above  the  iiyoid  bone ;  from  this  carry  a  second  one 
vertically  downward  along  the  median  line  of  the  trachea  to  the  incision 
made  to  open  the  trachea  ;  turn  the  flaps  outward  ;  remove  all  large  glands 
in  the  vicinity;  divide  the  muscular  attachments  to  the  hyoid  bone  ;  tie  tiie 
lingual  and  superior  thyroid  arteries ;  excise  the  tongue  below  the  disease, 
along  with  the  palato-pharyngeal  arches,  if  necessary,  carefully  avoidiiig  the 
external  carotid  arteries  when  it  is  possible ;  if  not  possible,  draw  them  for- 
ward along  with  the  pharynx  and  divide  them  between  two  ligatures;  cut 
the  lingual  and  hypoglossal  nerves.  The  larynx  is  now  separated  from  the 
trachea  by  cutting  the  latter  just  below  the  cricoid  cartilage ;  a  cannula  is 
introduced  into  it,  the  parts  are  thoroughly  washed  with  a  carbolized  solu- 
tion, the  flaps  placed  in  contact  with  the  raw  surfaces  without  sutures,  and 
the  wound  sprinkled  with  iodoform.  If  the  oesophagus  be  divided,  its  lower 
extremity  must  be  kept  open  and  so  placed  that  it  can  be  protected  from 
the  entrance  of  discharges,  and  become  an  available  channel  through  which 
to  nourish  the  patient. 

Partial  Laryngectomy. — Partial  laryngectomy  is  practiced  when  the  lim- 
ited extent  of  the  disease  does  not  require  the  removal  of  the  entire  organ. 
Half  of  the  larynx,  or  half  of  the  thyroid  cartilage,  with  or  without  the 
cricoid,  may  be  removed.  Inasmuch  as  the  same  dangers  are  incurred  as  in 
the  complete  operation,  although  in  a  lesser  degree  in  some  respects,  similar 
means  of  prevention  are  necessarily  employed.  The  incisions  relate  onlv 
to  the  affected  side.  The  organ  is  split  in  the  median  line  and  the  cavity 
examined.  The  thyroid  cartilage  is  carefully  removed  (page  1078),  cautiously 
avoiding  injury  of  the  pharynx.  The  associated  membranes  are  divided  as 
closely  as  practicable  to  the  cartilage.  The  superior  cornu  of  the  cartilage 
is  removed  with  strong  scissors  or  pliers.  The  epiglottis  is  usually  left  en- 
tire, and  the  aryteno-epiglottidean  fold  of  the  diseased  side  is  divided  close 
to  the  cuneiform  cartilage. 

TJte  Precautions. — Prompt  arrest  of  haemorrhage,  close  hugging  of  the 
cartilage  during  removal,  careful  avoidance  of  injury  to  the  a3sophagus, 
complete  asepsis,  and  the  prevention  of  ])ulmonary  infection  are  the  impor- 
tant features  of  the  operation. 

TIte  Remarks. — The  tampon  cannula  and  the  tracheotomy  tube  are  sub- 
ject to  the  same  use  as  in  the  complete  operation,  except  that  they  are  em- 
jiloyed  for  a  briefer  period.  The  cricoid  cartilage  may  be  removed  entire,  or 
half  only  may  be  taken  away  along  with  the  thyroid.  The  fact  that  cancer 
slowly  involves  the  cartilage,  causing  localized  death,  unattended  by  much 
infiltration,  suggests  the  practice  of  removal  of  circumscribed  disease  by  cut- 
ting and  scraping,  even  when  the  cartilage  is  superficially  involved.  We  are 
not  disposed  to  regard  with  favor  treatments  of  this  kind,  unless  for  some 


1082  OPERATIVE  SURGERY. 

special  reason,  and  then  only  when  a  strict  monthly  snrveillance  can  be 
exercised  to  note  any  evidences  of  return.  The  after-treatment  is  not  un- 
like that  of  the  complete  o})enition,  but  is  less  extended  because  of  the  less 
profound  nature  of  tlie  wound. 

Tlte  Results. — The  death  rate  of  partial  removal  is  lower  than  is  that  of 
complete  removal.  The  rate  of  final  cure  is  somewhat  less  in  the  former 
than  in  the  latter  method  of  practice. 

The  General  Remarks. — An  ordinary  tracheotomy  tube  can  be  fortified 
with  a  sponge  confined  in  place  around  the  tube  with  thread,  so  that  when 
wet  it  will  occlude  the  trachea.  Gussenhauer  regards  high  tracheotomy  as 
a  legitimate  part  of  the  procedure  and  performs  it  as  an  initial  step. 
Splitting  of  the  larynx  enables  one  to  determine  the  extent  of  the  disease, 
and  perhaps  save  a  part  of  the  organ.  There  appears  to  be  no  good  reason 
why  the  epiglottis  and  cricoid  cartilage  should  be  saved  even  though  not 
diseased  and  their  presence  is  sometimes  objectionable.  Enlarged  cervical 
glands  should  be  sought  for  and  removed.  Malignant  involvement  of  the 
soft  parts  outside  the  larynx  contraindicates  operation.  Only  the  trans- 
verse skin  incisions  are  sewed.  The  wound  is  stuffed  with  gauze,  which  is 
changed  every  eight  hours  or  so.  The  tampon  cannula  is  usually  removed 
and  the  tracheotomy  tube  substituted  after  two  or  three  days.  However, 
some  surgeons  employ  the  former  much  longer — ten  or  twelve  days.  Treves 
advises  that  a  rubber  tube  be  introduced  into  the  stomach  through  the 
oesophagus,  and  fastened  there  for  four  or  five  days,  and  even  longer,  for 
alimentary  purposes.  In  171  cases  preliminary  tracheotomy  was  omitted  in 
but  8.  The  tissues  should  not  be  bruised  or  torn  during  their  separation 
from  the  larynx,  but  instead  should  be  clean  cut.  Therefore,  suitable  room 
for  observation  and  treatment  should  be  secured  by  judicious  division  of 
restraining  tissues.  Complete  arrest  of  bleeding  is  necessary  before  opening; 
the  air  passages,  especially  if  preliminary  tracheotomy  has  not  been  done. 
Additional  caution  is  requisite  to  prevent  wound  infection  when  the  larynx 
has  been  split  before  removal. 

Keen's  Plan  of  Operation. — Keen.,  in  a  recent  address*  on  the  technique 
of  total  laryngectomy,  in  reporting  a  strikingly  successful  case  of  his  own,, 
dwelt  especially  on  the  preparatory  and  technical  steps  of  the  operation. 
He  advises  that  thorough  preliminary  disinfection  of  the  mouth,  naso- 
pharynx, and  larynx  with  suitable  antiseptic  solutions  be  frequently  made 
for  two  or  three  days  before  the  operation.  Thorough  and  frequent  use  of 
the  toothbrush  and  the  removal  of  offending  carious  stumps  are  also 
advised.  The  performance  of  tracheotomy  ten  days  or  two  weeks  before 
operation  is  counseled  in  cases  suffering  from  dyspncjea,  and  then  only  for 
improving  the  patient's  condition  and  not  to  prevent  the  entrance  of  blood 
to  the  trachea.  Tracheotomy  immediately  preceding  or  attending  the  opera- 
tion. Keen  does  not  regard  as  essential  in  all  cases,  and  when  thus  practiced 
the  opening  should  be  closed,  if  practicable,  as  soon  as  the  operation  is  com- 
pleted.    He  substitutes  when  advisable  the  Trendelenburg  position  for  the 

*  Transactions  of  the  American  Surgical  Association,  vol.  xvii,  1899. 


OPERATIONS   UN    TIIK   NKcK.  l(j^3 

use  of  the  vurioiis  tampon  caiuiuhv,  thus  removing  from  the  list  an  agent  of 
hindrance  and  of  special  danger.  Amesthetics  are  administered  through  the 
mouth  until  the  air  passage  is  o})ened,  when  a  large  tracheotomy  tube  is 
introduced,  through  whicii  anaesthesia  is  continued.  The  patient's  head  is 
kept  low  for  a  day  following  the  operation  by  raising  the  foot  of  the  bed. 
On  tiie  second  day  tlie  horizontal,  on  the  third  day  the  sitting  posture,  iind 
on  tiie  fourth  out-of-bed,  respectively,  is  advised.  Nutritive  enemata  are 
given  for  two  days,  followed  by  a  teaspoonful  of  liquid  food  every  half 
hour  by  tlie  mouth,  washed  down  by  a  tablespoonful  of  sterile  water.  At  the 
end  of  a  week  the  amount  is  much  increased,  solid  food  being  taken  after 
the  tenth  day.  In  the  reported  case  the  patient  could  swallow  from  the  first 
without  instrumental  aid.  Also  in  this  case  the  gauze  drain  was  removed  on 
the  following  day,  half  of  the  stitches  on  the  fourth,  and  the  remainder  on 
the  sixth  day  after  the  operation.  In  the  case  in  question  the  total  extirpa- 
tion followed  about  four  and  a  half  months  after  a  thyrotomy  performed  for 
cure  of  an  intralaryngeal  malignant  growth.  The  patient  was  placed  in  the 
Trendelenburg  position  and  a  median  incision  was  made  along  the  scar  of 
the  previous  operation.  The  thyroid  cartilage  was  split  in  halves,  the  bor- 
ders were  drawn  apart  to  determine  the  extent  of  the  disease,  and  thereby 
also  that  of  the  proposed  operation.  The  soft  parts  were  dissected  away  from 
the  sides  of  the  larynx,  the  median  incision  was  carried  down  nearly  to  the 
sternum,  the  trachea  exposed,  a  low  tracheotomy  done,  an  ordinary  large 
tracheotomy  tube  introduced,  the  inner  tube  then  removed,  and  the  chloro- 
form apparatus  connected  with  the  central  tube  by  means  of  the  metal  tube 
of  Hahn's  cannula.  The  trachea  was  then  divided  across  below  the  thyroid 
cartilage,  the  lower  end  of  the  larynx  drawn  forward  and  upward  by  means 
of  a  hook  and  the  finger,  and  the  posterior  surface  of  the  organ  was  separated 
from  the  oesophagus  by  means  of  the  finger  and  AUis's  blunt  dissector  as  far 
as  the  upper  border,  when  the  attachments  to  this  portion  were  divided  with 
scissors  and  the  larynx  was  removed.  The  epiglottis  was  also  removed. 
"  The  upper  edge  of  the  anterior  wall  of  the  pharynx  was  then  carefully 
attached  to  the  tissues  just  below  the  hyoid  bone  by  interrupted  silk  sutures 
placed  very  close  together,"  thus  shutting  off  the  secretions  of  the  pharynx 
and  mouth  from  the  wound.  The  upper  end  of  the  trachea  was  united  to 
the  skin  by  silk  sutures,  the  tube  removed,  and  the  tracheotomy  wound 
closed  by  suturing  the  rings  with  catgut,  and  the  remaining  tissues  of  the 
wound  by  silkworm-gut  sutures.  The  wound  above  the  exposed  end  of  the 
trachea  was  closed  by  silkworm-gut  sutures  and  a  small  gauze  drain  inserted 
at  its  lower  portion.  Xarrow  strips  of  folded  gauze  were  laid  above  and 
below  the  exposed  end  of  the  trachea,  which  was  then  protected  by  placing 
over  it  a  sterilized  wooden  pill  box  without  bottom  or  top,  covered  with  two 
or  three  layers  of  gauze  properly  fastened  to  the  contiguous  dressing.  The 
pill  box  and  gauze  were  removed  from  time  to  time  for  the  purposes  of 
cleanliness.  The  wound  healed  at  once  throughout  and  the  patient  made  a 
prompt,  complete,  and  uneventful  recovery. 

The  Remarks. — After  four  days  the  occasional  introduction  of  the  tube 
was  advisable  to  counteract  the  tendency  to  closure  of  the  open  end,  because 


1084 


OPERATIVE   SURGERY, 


of  contractiou,  and  to  the  iuturuiug  of  the  integumentary  borders.  As 
ah'eady  indicated  at  the  beginning,  the  stitches  should  be  removed  as  promptly 
as  possible.  In  indicating  briefly  the  future  technique  in  a  similar  case, 
Keen  says :  "  In  my  next  case,  after  dissecting  the  soft  parts  from  the  larynx 
and  upper  trachea  back  to  the  oesophagus  on  both  sides,  I  shall  place  the 
patient  in  the  Trendelenburg  position  and  deepen  the  narcosis  to  a  slight 
extent.  I  shall  then  divide  the  trachea  transversely,  and  by  three  sutures, 
one  in  the  middle  line  and  one  on  each  side,  shall  quickly  attach  the  tracheal 
stump  to  the  skin.  Then  I  shall  introduce  the  ordinary  tracheotomy  tube 
into  the  open  end  of  the  tracliea  instead  of  through  a  tracheotomy  wound, 
and  continue  the  anaesthetic  through  the  tube.  The  later  steps  of  the  opera- 
tion will  be  the  same  as  above  described.  In  order  not  to  embarrass  the 
operator  the  flange  of  the  tracheotomy  tube  should  only  |)roject  at  the  sides, 
as  the  usual  Avide  upper  border  of  the  flange  would  interfere  with  access  to 
the  parts  at  the  beginning  of  the  removal  of  the  larynx." 

The  plan  of  action  expressed  and  practiced  by  Keen  reduces  the  danger 
from  infection  to  a  minimum  and  shortens  the  time  of  operation.  In  suitable 
cases,  and  in  the  hands  of  experienced  operators,  the  arrangement  of  the  details 
will  without  doubt  greatly  improve  the  outcome  in  many  respects.  The 
amount  of  haemorrhage  is  comparatively  small  in  any  event  if  care  be  exer- 
cised in  the  selection  of  cases  and  in  their  treatment, 
utilization  of  the  artificial  larynx  is  prevented  in 
this  method  unless  a  secondary  operation  be  done. 


Fig.  1288.— Trendeleiihurs's  tam- 
pon, a,  h.  Tube  for  inflating 
rubber  bag  (c).     k.  Clamp. 


Fig.  1284. — Treiulelcnburg's  tampon  in  position. 
a.  Bag  for  inflation  of  tiie  tampon,  h.  ^Metallic 
funnel  covered  with  flannel  for  an;esthesia. 


Perier  recommends  the  performance  of  laryngectomy  without  pre- 
liminary tracheotomy  through  an  1 -shaped  incision  made  from  the  hyoid 
bone  to  below  the  cricoid  cartilage.  The  larynx  is  exposed  laterally,  two 
stout  threads  are  passed  through  the  trachea  at  the  site  of  proposed  divi- 
sion, the  trachea  is  severed,  and  a  special  tube  is  inserted  into  the  open 
end  through  which  anaesthesia  is  continued  while  the  operation  is  being 
completed. 

Tamponing  of  the  Tracliea. — Tamponing  the  trachea  calls  for  more  than 
passing  notice  because  of  the  acknowledged,  direct,  and  consequent  dangers 


Ol'KUA'I'IONS    ON    'llll';    .\i:('K. 


1085 


1285. — Tampon  at'k'r  Ilahn  and 
Michael. 


uliich  the  act  incurrf,  ami  also  oi'  tliu  gruwiug  teiuluiicy  to  ignore  tampon 
cannula'  altogetlier  w  hen  it  is  possible  to  supplement  their  utility  by  postural 
methods.  Tamponini;-  the  trachea  is  done  to  prevent  the  enti-ance  of  blood 
to  the  trachea  in  unusual  operations  on  tlie  larynx,  and  the  oral,  and  ])haryn- 

geal  cavitifs.  The  methods  most  often  em- 
ployed are  those  of  Trendelenburg  (Figs. 
Vzh  and  12.S4),  llahn  (Fig.  1285),  and 
(jlerster  (Fig.  128G).  The  first  is  provided 
with  a  thin  rubber  bag  so  adjusted  to  the 
tube  that  after  introduction  into  the  tra- 
chea it  can  be  inflated  with  air  by  a  rubber 
bulb.  If  it  is  to  remain  some  time  after 
the  operation,  water  or  glycerin  are  re- 
garded as  more  serviceable  tliiin  air.  In 
the  second,  medicated  sponge  is  substituted 
for  the  rubber  l)ag.  I'he  sponge  is  fash- 
ioned of  a  proper  shape  and  thickness,  fastened  around  the  tube  with  tliread, 
and  permitted  to  dry.  The  thread  is  then  removed,  leaving  the  sponge 
firmly  fixed  in  place,  which  is  then  covered  with  rubber  tissue  tied  in  posi- 
tion. The  extremity  of  the  tampon  is  introduced  and  the  sponge  moistened 
with  a  solution  of  boric  acid  injected  into  it  through  an  opening  in  the 
tube  by  a  hypodermic  syringe.  The  sponge  swells  and  closes  the  trachea, 
and  may  be  permitted  to  remain  in  place  for  some  time  provided  that  the 
discharges  of  the  wound  do  not  come  in  contact  with  it.  Tlie  third  form 
is  caused  to  fit  the  trachea  by  inflation.  The  mechanism  of  its  adjust- 
ment for  use  is  commendable.  However,  the  objections  to  the  use  of 
these  forms  of  apparatus  is  fast  leading  to  their  abandonment  when  pos- 
sible. The  rings  of  the  trachea  have  sustained  severe  injury  from  their 
introduction  and  from  joressure  necrosis.  The  failure  to  properly  close 
the  trachea  and  the  liability  of  the  rubber  to  rupture  have  been  followed 
by  annoying  complica- 
tions from  haemorrhage. 
A  too  great  distention 
may  cause  the  rubber 
tissue  to  balloon  and  ob- 
struct the  end  of  the 
tube.  Gerster's  appa- 
ratus seems  to  afford 
the  most  satisfaction 
of  any.  Each  of  these  | 
cannula  is  provided  for 
the  adjustment  of  a 
stereotyped  (Fig.  1284) 
or  extemporized  (Fig. 
747)  appliance  for  the  administration  of  the  anesthetic.  The  introduction 
into  the  open  end  of  a  tracheal  stump  of  a  large  ordinary  tracheotomy  tube 
supplemented   by  gauze   packing   around   it  is  a   prompt  and   serviceable 


12S(). 


ti-iicliea  tampon  cannula. 


108(3 


OPERATIVE  SURGERY. 


method  of  pnictice.  The  introduction  above  the  tube,  in  low  tracheotomy, 
of  pieces  of  iodoform  gauze  to  arrest  discharges  coming  from  above  are 
regarded  as  beneticial  in  diphtheria  and  infectious  discharges  from  other 
causes. 

TJie  Artificial  Lanjii.c  (Fig.  1287). — Within  four  or  iive  weeks  after  opera- 
tion, or  when  the  parts  are  well  healed,  the  artificial  larynx  may  be  inserted. 

At  that  time  competent  authority  should 
be  consulted  in  order  to  secure  the  most 
serviceable  apparatus  in  all  respects.  lu 
some  instances  the  artificial  larynx  gives 
but  little  trouble  and  adds  much  comfort 
to  the  patient;  in  others  its  use  is  but  little 
cultivated  and  often  quickly  discarded. 
Gussenbauer's  artificial  larynx  consists  of  a 
long  tracheal  tube  and  an  upper  short 
speaking  tube.  Wolff's  apparatus  is  by 
some  regarded  more  efficient  than  tlie 
former.  A  T-sha]oed  tube  is  preferred  by 
some  patients,  although  it  affords  only  the 
lisping  voice.  Methodical  exercise  will  often  enable  a  patient  to  speak 
aloud  without  the  use  of  an  artificial  appliance. 

The  Results.  — The  operation  has  been  performed  upward  of  300  times, 
over  two  thirds  of  which  were  complete  removals.  The  rate  of  mortality 
from  the  operation  alone  is  over  80  per  cent  in  complete  cases,  but  less  in 
the  incomplete.  Early  return  is  the  rule  in  complete  removal.  According 
to  Butlin,  in  1890,  the  following  results  for  operation  in  malignant  diseases. 
are  noted  after  from  three  to  twenty  years  have  elapsed : 


Pig.  1387.- 


-Giissenbauers  artificial 
larynx. 


Number  of  cases. 

Deatlis  froinoperation. 

Cures. 

Thyrotomy 

28 
23 
51 

3 
16 

3 

Partial  excision 

4 

Complete  excision 

8 

102 

26 

15 

Later  estimates  show  a  death  rate  of  22  per  cent,  a  positive  cure  (three 
years  or  more)  of  10  per  cent,  a  relative  cure  (less  than  three  years)  of  48  per 
cent,  and  a  recurrence  of  20  per  cent  (Schmiegelow).  Earlier  action  and 
improved  technique  will  no  doubt  increase  considerably  these  results. 

Operations  on  the  Thyroid  Body. — An  enlarged  thyroid  body  is  removed 
partially  or  completely,  not  infrequently,  and  otherwise  surgically  treated  to 
afford  relief  from  physical  suffering  and  the  mental  disquietude  which  the 
deformity  due  to  its  presence  causes.  Complete  removal  is  not  practiced 
now  except  for  malignant  disease,  on  account  of  the  unfortunate  sequels 
due  to  its  removal  from  the  human  economy.  At  the  present  time  the  fol- 
lowing operative  procedures  are  employed  in  the  surgical  treatment  of  goitre : 
1,  Partial  excision  ;  2,  enucleation' — resection  ;  3,  enucleation  ;  -4,  ligature  of 


Ol'KlfA  rioNS   ()\    TIIK    NKCK.  Joy^ 

the  iirtorit's  tiiul  e.vOtliyro[texy.  ('(jiiiplcLe  excision  is  practiced  in  nialigutuit 
cases  only,  and  with  great  conservatism. 

The  Aiiatoinicd/  I'oints. — The  rehitions  of  the  normal  thyroid  body  to  the 
trachea,  cesophagus,  recurrent  laryngeal  nerves,  and  to  the  carotid  sheatli  and 
its  contents,  should  be  given  careful  consideration  before  beginning  the  opera- 
tion. The  shape,  si/e,  nature,  and  extent  of  the  growth  will  modify  in  a 
marked  degree  its  nornud  relations  to  important  structures,  and  have  much 
to  do  to  establish  or  disprove  the  idea  of  operative  action.  The  inferior  thyroid 
arteries  are  larger  than  the  superior,  but  the  anastomosis  between  them  all 
is  of  the  freest  kind.  The  right  superior  thyroid  artery  was  absent  in  a 
case  of  removal  by  the  author.  The  arteria  thyroidea  ima  supplements 
often  the  deficiency  due  to  anomalies  of  the  regular  arterial  supply  of  the 
body.  The  superior  and  inferior  thyroid  veins  are  of  large  size,  are  inti- 
mately associated  with  the  arteries  of  the  same  name,  and  empty  their  blood 
into  the  internal  jugular  and  innominate  veins  respectively.  The  su])erior 
thyroid  arteries  approach  the  anterior  and  upper  parts  of  the  organ  which 
they  mainly  supply.  The  inferior  lie  below  and  posteriorly  to  the  organ, 
and  supply  chiefly  the  corresponding  portion  of  this  body.  The  recurrent 
laryngeal  nerves  are  closely  and  indefinitely  associated  with  the  inferior 
arteries,  and  for  this  reason  extra  care  is  needed  to  prevent  injury  of  them 
during  ligature  of  these  vessels.  The  sympathetic  nerves  and  the  middle 
cervical  ganglion  are  in  quite  intimate  relations  with  the  inferior  thyroid 
arteries,  and  great  care  should  be  exercised  to  avoid  injury  of  them.  Por- 
tions of  glandular  tissue  of  small  size  and  separated  from  the  main  structure 
are  found  from  the  arch  of  the  aorta  to  the  hyoid  bone.  These  accessory 
bodies  are  of  much  importance,  as  they  may  become  the  seat  of  carcinoma- 
tous growths.  The  location  of  the  third  lobe  and  its  relation  to  the  isthmus 
and  to  contiguous  structures  should  be  noted.  It  is  sometimes  the  seat  of 
disease,  and  it  is  important  to  know  that  when  healthy  it  often  remains 
behind  in  complete  extirpation  of  the  major  lobes.  The  thyroid  body  is 
covered  in  front  by  the  sterno-hyoid,  the  sterno-thyroid,  the  omo-hyoid,  and 
the  anterior  border  of  the  sterno- mastoid  muscles.  It  lies  between  two  lay- 
ers of  fascia  which  unite  above  and  are  attached  to  the  cricoid  cartilage.  A 
distinction  should  be  made  between  the  fascial  covering  and  the  proper  cap- 
sule of  the  thyroid  body,  otherwise  great  confusion  will  attend  the  isolation 
of  the  gland  from  its  contiguous  tissues.  The  atrophy  of  the  tissues  over- 
lying the  enlargement  may  be  mistaken  for  the  capsule  of  the  thyroid  body 
itself. 

Tlte  prepanifion  of  the  patient  is  not  essentially  dissimilar  from  that  for 
operations  generally  at  this  region.  The  nsual  local  aseptic  measures  are 
practiced.  The  bowels  should  be  unloaded  freely  the  day  before  the  opera- 
tion to  obviate  the  need  of  defecation  for  the  first  few  days  afterward. 
Chloroform  anaesthesia  is  preferable  in  this  as  in  most  other  operations  at 
this  situation.  The  patient  is  placed  on  the  back,  with  the  shoulders  raised, 
and  the  neck  extended  and  well  exposed. 

The  Operation  of  Partial  Eu:cision  (Kocher). — Either  a  transverse  or 
angular  incision  may  be  employed.     If  the  tumor  be  small  and  cosmetic 


1088 


OPERATIVE  SURGERY. 


gain  bo  important,  make  a  liberal  transverse  incision  with  a  slightly  upward 
convexity  along  the  line  of  cleavage  of  the  skin,  across  the  most  prominent 
part  of  the  tumor,  through  the  integument  and  platysma,  catching  the 
superficial  vessels  and  dividing  them   between  two   ligatures ;   divide  the 

fascia    and    expose    the 
spread-out  fibers  of  the 
sterno  -  laryngeal       and 
sterno- mastoid  muscles; 
divide  the  former  mus- 
cles and  the  border  of  the 
latter  so  that  the  tumor 
may  be   freely   exposed 
(Fig.   1288).     The  fur- 
ther detail  is  stated  un- 
der operation  by  angu- 
lar incision  (page  1089). 
The  Remai'hs. — 
iT       Although  the  trans- 
verse incision  is  fol- 
lowed    only    by    a 
minimum  degree  of 
%       scarring,  the  retrac- 
tion of  the  divided 
muscles  often  causes 
a  marked  and  even  ugly 
deformity.       Therefore, 
the  muscles  should   not 
be  divided  unless  their 
division  be  necessary  for 


iL 


y 


iiiU^^ 


Fir.. 


1288. — Tlie  operation  of  excision  of  goitre  of  the  right 
side,  Kocher's  method,  a.  Branch  of  coinniunication 
between  anterior  and  external  jugular  veins,  h.  Sterno- 
cleido-mastoid  muscle,  c.  Sterno-thyroid  muscle,  d. 
Anterior  jugular  vein.     e.  Sterno-hyoid  muscle. 


a  proper  exposure  of  the 
tumor.  If  the  incision  be  incautiously  made  or  extended  at  either  end 
the  external  jugular  veins  may  be  divided. 

The  angular  incision  causes  a  more  pronounced  scarring,  but  permits  of 
separation  of  muscular  fibers,  thus  avoiding  the  deformity  that  follows  their 
division.  Inasmuch  as  the  operative  steps  are  comparatively  similar  after 
exposure  of  the  growth  through  either  incision,  and  as  the  transverse  has 
been  described  already,  the  angular  incision  and  removal  of  the  growth  will 
be  stated  in  detail. 

The  Angidar  Incision. — Commence  the  angular  incision  at  the  level  of 
the  thyroid  cartilage  over  the  prominence  of  the  sterno-mastoid  muscle,  and 
extend  it  transversely  in  the  direction  of  the  skin  creases  to  the  median  line 
of  the  neck,  thence  vertically  downward  even  to  the  suprasternal  notch,  if 
the  size  of  the  tumor  demands  (Fig.  1289),  cutting  through  the  skin,  fascia, 
and  platysma,  dividing  the  vessels  between  two  ligatures  as  they  appear; 
expose  the  fibers  of  the  sterno-mastoid  at  the  outer  part  of  the  incision  ; 
free  the  border  of  the  muscle  and  draw  it  aside  with  hooks;  incise  and 
draw  upward   the   fascia  that  covers  the  sterno-hyoid   and   sterno-thyroid 


OPKRATIONS   ON    TIIK   NHCK. 


1089 


niiisclos  :it  the  jiiiddle  })ortiou  of  the  hurizuntul  incision  ;  divide  in  the 
median  line  the  fascia  that  connects  the  sterno-laryngeal  muscles  of  the 
respective  sides,  ligaturing  the  vein  that  lies  transversely  above  the  supra- 
sternal notcii ;  free  the  inner  edges  of  these  muscles,  introduce  the  finger 
under  and  partially  divide  them  at  the  upper  ends;  ligature  divided  vessels 
and  draw  aside  with  hooks  the  borders  of  these  muscles,  thus  exposing  the 
outer  capsule  of  the  goitre;  carefully  divide  and  strip  to  either  side  from  the 
surface  of  the  tumor  this  capsule  with  a  blunt  dissector;  divide  between  two 
ligatures  the  transverse  veins  when  seen  stretching  between  the  capsule  and 
the  goitre;  draw  aside  the  outer  capsule  along  with  the  superimposed  mus- 
cles sufficiently  to  permit  the  finger  to  be  cautiously  ])assed  around  the  edge 
of  the  goitre  and  beneath  its  under  surface ;  draw  the  goitre  forward  care- 
fully (Figs.  1290  and  1291), 
tearing  no  vessels,  especial- 
ly the  inferior  thyroid  ar- 
tery and  its  branches,which 
are  considerably  stretched 
by  traction ;  ligature  the 
inferior  thyroid  artery  and 
its  veins  behind  the  tumor 
as  soon  as  they  are  suffi- 
ciently exposed ;  carefully 
isolate  and  inspect  the  in- 
ferior thyroid  artery  before 
ligature  to  avoid  involve- 
mentof  the  recurrent  laryn- 
geal nerve  (Fig.  1294, 
k).  If  the  accomplish- 
ment of  this  purpose  be 
too  difficult  or  uncer- 
tain, it  should  be  de-  ^ 
ferred  until  a  later  stage 
of  the  procedure.  When 
the  lower  part  of  the  tu- 
mor does  not  extend  be- 
neath the  sternum,  the 
large  inferior  thyroid  vein 
is  put  on  the  stretch,  iso- 
lated, and  tied  between  two 
ligatures  by  drawing  this 
portion  of  the  tumor  forward.  Isolate  and  divide  between  two  ligatures  a 
branch  of  the  superior  thyroid  vein  which  ascends  toward  the  median  line ; 
expose  the  superior  thyroid  vessels  by  blunt  dissection  made  above  the  isthmus 
at  the  inner  border  of  the  upper  horn  of  the  growth ;  draw  the  outer  capsule 
and  the  superimposed  soft  parts  upward,  grasp  the  upper  horn  with  the  thumb 
and  finger,  and  put  on  the  stretch  the  superior  thyroid  vessels,  which  are  then 
tied  and  divided ;  isolate  and  ligature  the  veins  lying  above  and  below  the 


Fir 


1289. — The  operation  of  excision  of  goitre  of  left 
side  by  angular  incision.  Kocher"s  method,  a.  An- 
teriorjugular  vein.  h.  Sterno-hyoid  nuiscle.  c. 
Communicating  branch  between  anterior  and  exter- 
nal jugular  veins,     d.  Inferior  thyroid  veins. 


1090 


OPERATIVE   SURGERY. 


%   L^ 


respective  borders  of  the  isthmus;  insinuate  carefully  between  the  trachea 
and  the  isthmus  an  aneurism  needle  or  Kocher's  grooved  director  (Fig.  1292), 
and  surround  the  latter  structure  by  a  strong  silk  ligature,  which  is  tight- 
ened as  the  isthmus  is  cut  across;  push  the  tingers  of  the  left  hand  under 
the  goitre,  and  raise  it  upward  while  its  firm  attachments  are  being  sepa- 
rated from  the  trachea.  Finally,  the  tumor  is  turned  carefully  out  of  its 
bed  while  observing  for  the  presence  of,  and  cautiously  treating,  any  restrain- 
ing tissues. 

The  Precafitions. — The  patient's    neck  should  be  flexed  from  time  to 
time,  in  order  that  small   veins  emptied   by  extension   may  fill  again  and 

_  escape    untimely     divi- 

-"-^"^^  sion.         If    the   proper 

capsule  of  the  growth 
be  not  entered  at  first, 
the  aimless  efforts  to 
isolate  it  will  cause  great 
embarrassment  and  lead 
to  harmful  delay.  The 
application  of  the  liga- 
ture to  the  thyroid  ves- 
sels at  a  distance  from 
the  growth,  or  the  use 
)f  temporary  ligatures, 
should  be  prac- 
ticed when  prop- 
er isolation  of 
the  recurrent 
laryngeal  nerve 
is  not  assured. 
During  the  sepa- 
ration of  the  goi- 
tre from  the  trachea  the 
recurrentlaryngealnerve 
may  be  injured  "  in  spite 
of  every  care,"  especial- 
ly where  it  passes  be- 
neath the  lower  border 
of  the  larynx.  To  pre- 
vent this  accident  Koch- 
er  advises  that  a  poste- 
rior portion  of  the  capsule  of  the  growth  be  cut  away  and  left  behind  at  that 
situation.  In  instances  of  encapsulated  thyroid  nodules,  not  separable  poste- 
riorly from  the  internal  thyroid  capsule,  the  capsule  must  be  cut  through, 
"but  not  sufficiently  near  to  the  trachea  to  beget  a  dangerous  removal.  The 
possible  adhesion  of  large  growths  to  the  jugular  vein  should  not  be  over- 
looked. Undue  compression  upon  or  a  kinking  of  the  pressure-softened 
trachea  by  rough  handling  may  cause  alarming  and  perhaps  fatal  dyspnoea. 


Fig.  1290. — The  operatinii  of  excision  df  goitre  of  right  side 
through  transverse  incision  (Fig.  1288),  Kocher's  method. 
a.  Superior  thyroid  artery  and  vein.  h.  Posterior  bor- 
der of  thyroid  cartihige.  c.  Sterno-hyoid  and  sterno- 
thyroid muscles,  d.  Sterno-cleido-niastoid  muscle,  e. 
Inferior  thvroid  artery.  /.  Right  common  carotid 
artery,  g.  Right  recurrent  laryngeal  nerve.  1\.  QCsopli- 
agus.'  i.  Trachea.  _;'.  Inferior  thyroid  vein.  A\  Right 
half  of  goitre  turned  out  toward  the  left  side. 


(>1'i;i;a'1'|(>ns  on    i'iik  xkck. 


Kiiil 


"^^ 


Since  the  liu'inonliage  ami   llie  peculiar  fever  that  ofien  follow  operation 
are  increased  in  direct  proportion  to  the  amount  of  laceration  of  the  thy- 
roid botly  attemling  the  removal,  nei'tlk-ss  injury  of  tlif  structure  slnjuld  bo 
carefully   avoided.        Re- 
move promptly   lluid  col- 
lections from  the  pharynx 
to   prevent  strangulation. 
Vertical    incisions  for  re- 
moval   of    goitre    should 
rarely  be  made. 

The(  'oNiine/t/s. — A  pair 
of  blunt- pointed  scissors 
curved    on    the    flat    are 
efficient    instruments   for 
enucleation  purposes.      A 
bronchocele  may  not  only 
surround  the  trachea, 
but  so  insinuate  itself 
with  other  important 
structures  as  to  make 
the  removal  impossi- 
ble,  or    the    attempt 
unjustifiable.    Kocher  ad- 
vises the  employment  of  lo- 
cal anaesthesia  in  all  cases 
attended      with      marked 
dyspncea.     General  anaes- 
thesia causes  engorgement 
of    the   vessels,    increases 
the  hfemorrhage,  and  in- 
cites   secondary    bleeding 
by   consequent    vomiting. 
Koclier  advises  the  use  of 

a  one-per-cent  solution  of  cocain  in  all  suitable  cases,  and  regards  the  dan- 
gers as  being  greatly  lessened  by  local  anaesthesia.  But  little  pain  is  caused, 
and  the  consciousness  of  the  patient  will  permit  of  his  co-operation,  and  of 
the  recognition  of  involvement  of  the  recurrent  laryngeal  nerve  by  noting 
the  character  of  the  voice.  Blind  and  hurried  clamping  of  bleeding  points 
should  not  be  practiced  in  this  operation. 

Enucleation — Resection  (Kocher). — Enucleation-resection  is  advised  by 
Kocher  as  being  superior  to  enucleation,  because  of  the  severe  haemorrhage 
that  often  attends  enucleation,  and  the  resulting  need  of  packing  the  wound; 
also  the  consequent  danger  of  sepsis,  the  delay  in  healing  that  follows  packing, 
and  the  less  certainty  of  permanent  cure  in  cases  of  multiple  growth  and 
those  of  questionable  nature,  than  when  excision  is  practiced.  WoJfler  con- 
curs in  these  reasons. 

Expose  the  goitre  through  the  transverse  or  angular  incision,  as  seems 
75 


Fig.  1291. — The  operation  of  excision  of  left-sided  goitre, 
angular  incision,  Kocher's  method,  a.  Superior  thy- 
roid vein.  b.  Superior  thyroid  vessels,  c.  Sterno- 
mastoid  muscle,  d.  Sterno-hyoid  muscle,  e.  Infe- 
rior thyroid  artery.  /.  Inferior  thyroid  vessels,  g. 
Goitre  dislocated  to  tlie  right  over  trachea.  The  in- 
ferior and  superior  thyroid  arteries  ami  veins  are 
ligatured. 


1092 


OPERATIVE  SURGERY. 


U 


best;  dislodge  tlie  growth  as  before  described  (page  1080),  omitting  ligature 
of  the  vessels;  ligature  and  divide  the  istlimus  as  in  the  preceding  instance 
(page  1090) ;  expose  the  inner  border  of  tlie  nodule  to  be  enucleated  through 
the  cut  following  division  of  the  isthmus;  separate  the  nodule  from  the 
overlying  gland  tissue  with  a  blunt  dissector;  divide 
the  overlying  gland  tissue  along  the  line  indicated  by 
tlie  needles  (Fig.  1293)  between  tvvo  ligatures;  sej^arate 
the  nodule  at  the  upper  and  lower  parts  from  the  inner 
capsule  with  the  finger;  free  a  fair  extent  of  the  poste- 
rior surface  in  tlie  same  manner;  divide  the  posterior 
l^art  of  the  inner  capsule  vertically  at  the  posterior  sur- 
face with  scissors,  so  that  the  cut  opens  into  the  line  of 
section  made  just  before  at  the  anterior  surface  (Fig. 
1293,  ^•) ;  remove  the  nodule  and  the  part  of  the  gland 
lying  in  front  of  it,  and  close  the  wound. 

The  Precmitions. — In  cutting  away  the  thyroid  struc- 
ture, do  not  approach  sufficiently  near  to  the  tracliea  to 
invite  danger  to  it  or  to  the  laryngeal  nerve. 

Enucleation  (Socin). — Expose  the  surface  of  the  goitre 
tlirough  a  median  incision,  or  one  made  over  tlie  anterior 
border  of  the  sterno-mastoid,  according  to  the  promi- 
nence of  the  growth  (Socin).  Separate  the  sterno-laryn- 
geal  muscles  and  draw  their  borders  apart ;  draw  aside 
the  omo-hyoid  if  practicable,  if  not,  divide  it ;  expose  the 
surface  of  the  tumor  by  division  of  the  overlying  tissue 
at  the  situation  of  the  nodule.  It  is  recognized  by  its  bluish  white  covering, 
and  enucleated  through  the  incision  made  down  upon  it,  deeply  or  super- 
ficially, as  the  case  may  be,  arresting  haemorrhage  as  it  occurs. 

The  Comments.  The  Incisioji  of  Kocher. — The  recurrent  laryngeal  nerve 
is  not  exposed  to  danger  in  this  operation  ;  the  healthy  structure  of  the  organ 
la  preserved,  and  deformity  is  prevented.  Attempted  cure  by  injection 
complicates  enucleation.  In  some  instances  haemorrhage  is  quite  profuse. 
Temporary  or  permanent  ligature  of  the  arteries  may  be  practiced.  However, 
the  indication  is  commonly  well  met  by  elastic  constriction  around  the  neck 
of  the  affected  part  of  the  gland  (Hose).  This  operation  is  adapted  to  the 
cure  of  cysts  and  solid  tumors  of  established  size,  but  not  to  advancing 
goitre,  as  tlien  recurrence  is  quite  certain.  A  free  incision  may  not  be 
required  for  the  removal  of  each  independent  cyst,  as  a  contiguous  cyst  may 
be  removed  through  the  thin-walled  compartment  of  another. 

Enucleation  is  regarded  by  many  operators  Avith  great  favor.  Nearly 
2,700  cases  are  reported  in  which  neither  hiemorrhage,  sepsis,  nor  cachexia 
caused  death.  Operative  involvement  of  the  recurrent  laryngeal  nerves  and 
of  other  important  contiguous  structures  are  less  frequent  than  in  the  more 
extended  operations.  Shepard  strongly  favors  the  method  in  both  solid  and 
cystic  tumors.  In  their  removal  he  adheres  closely  to  the  outer  limits  of 
each;  in  the  latter  he  taps  the  sac,  grasps  it  with  forceps,  and  carefully 
removes  it.     In  each  instance  haeinorrhage  is  arrested  by  ligature  and  gauze 


Fig.  1292.— Koeher's 
grooved  director 
for  operations  on 
goitre. 


urKKATIoNS   ()X     rUK    NKCK. 


1093 


packing,  tho  wound  siituii'd  ;ibuve  uikI  left  oi)t'n  below  for  rcmoviil  of  the 
gauze. 

Resection  of  Goitre  {Tlnjraidecloiny)  (Kocher). — Resection  of  the  growth 
is  sometimes  practiced  for  relief  from  the  severe  pressure  symptoms  inci- 
dent to  colloid  degeneration  of  both  lobes,  or  of  the  malignant  complica- 
tions, as  well  as  for  their  cure.  A  long  transverse  incision  is  made  with  an 
upward  extension  at  both  ends,  followed  by  a  free  transverse  division  of 
the  muscles,  with  ligature 
of  the  main  vessels  of  one 
side  and  a  vessel  above  or 
below  on  the  other  side. 
When  practicable  forward, 
successive  luxation  of  the 
respective  halves  of  the 
growth  is  done,  and  resec- 
tion practiced  under  elas- 
tic tension,  snpplemented 
with  numerous  artery  for- 
ceps. In  this  way  only  can 
partial  removal  of  both 
lobes  be  practiced  with- 
out extensive  haemor- 
rhage when  cutting 
through  the  thyroid 
tissue.  The  overlying 
structures  involved  in  ma- 
lignant growths  should 
also  be  dissected  away. 

The  Remarks.— ki  the 
best,  resection  of  a  goitre 
is  a  difficult  and  often  a 
dangerous  measure.  In 
this  class  of  cases  difficulty 
of  breathing  is  frequently 
present.  And  in  these,  as 
in  others  similarly  afflict- 
ed, ether  is  contraindi- 
cated.  Slight  morphin 
narcosis  and  cocain  an- 
aesthesia should  be  employed  instead.  In  so-called  complete  extirpation  a 
small  portion  of  gland  is  left,  and  often  a  pyramidal  process  (third  lobe) 
remains.  Ligature  and  division  of  the  isthmus  has  been  advised  for  the 
relief  of  pressure  dyspnoea  in  inoperable  cases.  WblJJer  practiced  "opera- 
tive dislocation "  for  the  same  purpose,  the  goitre  being  raised  from  its 
bed  without  cutting  the  arteries,  and  transplanted  to  a  more  favorable 
situation.  In  malignant  disease  the  fatal  outcome  is  so  pronounced  as  to 
almost  forbid  the  practice.     Thirty-three  per  cent  die  from  the  oiJeration, 


/' 


y 


Fig.  129.3. — The  operation  of  enucleation — resection  of  a 
hypertrophied  nodule  from  the  left  lobe.  Kocher's 
method,  a.  Angle  of  thyroid  cartilage,  b.  Cricoid 
cartilage,  c.  Piece  of  posterior  portion  of  capsule  of 
goitre.  (1.  Ligatured  isthmus,  e.  Healthy  portion 
of  thyroid.  /.  Trachea,  g.  Inferior  thyroid  vein. 
h.  Upper  horn  of  thyroid  and  superior  thyroid  ves- 
sels, i.  Cut  surface  of  isthmus,  j.  Surface  of 
nodule,  k.  Line  of  division  of  capsule  of  goitre  at 
posterior  surface.  (This  line  is  located  too  far  for- 
ward.) I.  Lower  horn  of  thyroid.  The  left  lobe  is 
dislocated  through  the  incision,  isthmus  ligatured, 
cut  across,  and  the  cut  surfaces  drawn  apart  so  as  to 
expose  nodule. 


1094  OPERATIVE  SURGERY. 

and  60  per  cent  die  within  six  and  84  per  cent  within  eight  months  after 
operation. 

The  Treatment  by  Ligature  of  the  Thyroid  Arteries. — The  ligature  of  the 
superior  tliyroid  is  not  (iiHicult  or  especially  dangerous  (page  1T3).  Ligature 
of  the  inferior  thyroid  is  more  difficult,  and  incurs  special  dangers  from  the 
involvement  of  important  structures  (page  153).  Kocher  reaches  the  ves- 
sel through  an  incision  made  along  the  inner  border  of  the  sterno-mastoid, 
and  ties  the  artery  in  front  of  the  scalenus  anticus.  Rydygier  made  a  trans- 
verse incision  three  inches  in  length,  one  inch  above  the  clavicle,  so  that 
more  than  half  the  length  lies  behind  the  sterno-mastoid  muscle,  through 
which  he  exposes  the  thyroid  axis,  and  secures  and  ligatures  the  artery. 

The  Comments. — The  rapidly  developing  parenchymatous,  vascular 
goitres,  especially  in  the  young  and  those  unfitted  for  enucleation,  are  proper 
cases  for  treatment  by  ligature.  The  gradual  atrophy  following  simultane- 
ous ligature  of  both  of  the  arteries  does  not  appear  to  expose  the  patient  to 
the  common  sequels  of  complete  removal  of  the  thyroid  body.  The  vascular 
goitre  of  Graves's  disease  is  suited  to  this  procedure.  Tyendelenhurg  ties  the 
arteries  of  one  side,  a  month  later  those  of  the  other.  WiJlJJe}-  and  Porta  have 
practiced  the  same  with  favorable  results.  Kocher  advises  that  the  artery 
supplying  the  portion  of  the  thyroid  involved  should  be  tied  first,  and  be 
followed  by  ligature  in  order  of  the  vessels  supplying  succeeding  enlarge- 
ments, provided  that  a  beneficial  effect  be  noted.  The  different  plans  of 
action  advised,  and  the  uncertainty  of  the  outcome  from  the  ligature,  to- 
gether with  the  difficulty  attending  it  in  many  instances  when  compared  with 
the  established  technique  and  success  of  the  radical  methods,  leave  but  a  lim- 
ited field  of  utility  in  this  disease  for  ligature. 

Exothyropexy  (Jaboulay). — Exothyropexy  consists  in  freeing  the  gland 
from  its  capsular  environment,  raising  and  fixing  it  superficially  in  the 
wound,  and  leaving  it  to  granulate  and  adhere  under  antiseptic  dressing. 
The  influence  of  exposure  to  air,  and  of  resulting  venous  sinus  thrombosis, 
contribute  to  the  shrinkage.  Poncet,  Wdlffer,  and  others  have  secured  in 
this  manner  a  limited  shrinkage  of  the  gland.  The  presence  of  thrombosis 
and  the  laceration  attendant  on  the  displacement  are  elements  of  danger 
from  systemic  infection.  In  cases  of  threatened  suffocation  high  or  low 
tracheotomy,  according  to  the  size  and  situation  of  the  goitre,  with  the  in- 
troduction of  a  tube  suited  to  the  peculiar  requirements  of  the  case  (Fig. 
12T0),  is  a  wise  preliminary  step  and  often  a  jiroper  final  measure.  It  seems 
especially  fitted  for  the  relief  of  dyspnoea  of  parenchymatous  and  other  in- 
operable goitres.  Larger  experience  is  required  to  establish  the  practicability 
of  the  measure. 

Excision  of  the  Sympathetic. — JnhovJay  and  Jojinesco,  have  advised  and 
practiced  this  measure  for  the  relief  of  patients  with  exophthalmic  goitre 
(page  1282). 

The  injection  of  goitre  for  cure  is  now  practiced  much  less  than  formerly. 
Injection  should  not  be  employed  at  all  in  cases  for  which  operation  is 
contemplated,  on  account  of  the  periglandular  adhesions  that  it  causes, 
which  beget  special  difficulties  in  the  event  of  subsequent  operation.     The 


OPERATIONS   ON    TIIK    NKCK.  1(,95 

cystic  and  recent  follicuhir  viuieties  are  those  to  wliicli  the  treatment  is  best 
suited.  The  excellent  results  now  obtained  by  operation  limit  the  use  of 
injections  to  tlie  narrow  and  illogical  Held  of  unsurgical  cxiicdiency.  "i'lie 
tincture  of  iodine  (live  to  ten  dro])s)  and  a  like  amount  of  carbolic-acid  solu- 
tion (live  per  cent)  are  regarded  as  the  best  medicinal  agents  for  tlie  pur- 
pose. Strict  aseptic  i)recautions  throughout  should  be  taken.  The  needle 
should  be  thrust  slowly  into  the  gland,  carefully  avoiding  the  suj)erficial 
veins  ;  the  syringe  is  then  removed  to  see  if  blood  will  escape  through  the 
needle,  thus  avoiding  the  introduction  of  the  fluid  into  a  vein.  Eight  or  ten 
drops  of  the  fluid  are  then  slowly  injected,  watching  carefully  the  eftects  of 
the  introduction.  But  one  injection  is  made  at  a  sitting,  and  an  interval  of 
three  or  four  days  should  have  elapsed  before  it  is  repeated.  Diflerent 
aspects  of  the  tumor  are  subjected  to  treatment.  Senn  speaks  in  high  terms 
of  the  carbolic-acid  treatment  established  by  Gunn.  t<cliii'avtz  regards 
iodine  as  the  most  eflicacious  and  least  dangerous  for  ordinary  cystic  goitre. 
Heynutun  reports  IG  deaths  from  injection,  one  of  which  happened  suddenly 
after  the  use  of  iodine,  which  had  been  injected  twice  jier  week  for  four 
months. 

The  Dangers  of  the  Operations. — Haemorrhage  is  a  constant  danger  dur- 
ing, and  it  may  lia])pen  after,  the  operation.  If  care  be  exercised  to  divide 
nothing  incautiously  and  to  divide  the  vessels  between  two  ligatures,  but  lit- 
tle annoyance  is  likely  to  hapj^eu  from  this  cause  during  operation,  unless  the 
growth  be  a  soft  and  highly  vascular  one,  when  a  startling  and  profuse  bleed- 
ing will  be  provoked  by  opening  the  capsule.  The  difficulty  of  finding  and 
securing  the  bleeding  points  in  such  cases  is  often  trying,  and  may  seriously 
test  the  composure  of  the  surgeon.  If  careful  scrutiny  be  exercised  to  de- 
tect bleeding  points  before  the  wound  is  closed,  and  the  ligatures  have  been 
securely  placed  during  ojieration,  no  rational  fear  need  be  felt  regarding 
haemorrhage  thereafter.  The  danger  of  the  entrance  of  air  into  the  veins  is 
especially  iironiinent  here  because  of  their  great  number,  large  size,  and  inti- 
mate relation  with  the  influence  of  respiratory  aspiration.  These  same 
peculiarities  contribute  to  the  danger  from  the  use  of  injections,  and  the  pres- 
ence of  thrombi  and  infecting  agents. 

The  Recurrent  Luryngecd  Nerve. — If  this  nerve  be  cut,  bruised,  or  in- 
cluded in  a  ligature  during  operation,  serious  laryngeal  manifestations  may 
occur  at  the  time  or  may  happen  afterward.  Undue  dragging  on  the  nerve, 
its  involvement  in  cicatricial  formation,  or  the  presence  of  neuritis  may  cause 
aphonia  after  operation.  Fortunately,  however,  these  manifestations  are  not 
always  permanent.  Large,  adherent,  illy-defined  tumors  are  dangerous  for 
this  reason,  as  are  those  surrounding  closely  the  trachea  and  a-sophagus.  A 
subsequent  operation  may  be  necessary  to  relieve  these  symptoms.  The  lym- 
phatic duct,  especially  the  right,  may  be  bruised  or  torn  during  the  removal 
of  large  or  low  goitres.  The  distinctive  appearance  of  the  lymph  will  sug- 
gest the  nature  of  the  structure  involved. 

Cellulitis. — Cellulitis  of  a  septic  nature  may  follow  operation  even  for 
small  growths,  and  lead  to  the  formation  of  pus  in  the  mediastinum.  A 
scrupulous  aseptic  technique  will  obviate  this  danger. 


109(3  OPERATIVE  SURGERY. 

Cachexia  Thyreopriva. — Cachexia  thyreopriva  manifests  its  presence  by 
a  species  of  tetany  and  myxo^deina.  The  continued  and  frequent  occurrence 
of  these  sequels  in  coni2)lete  extirpation  led  to  its  abandonment  except  in 
malignant  disease.  The  removal  of  a  greater  or  lesser  fractional  part  of  the 
gland  may  be  followed  by  these  sequels  in  a  minor  degree.  However,  the 
best  evidence  of  their  iufrequency  is  witnessed  by  the  fact  that  in  1,G0U  cases 
of  operation  by  Kocher's  method  but  4  suffered  from  this  sequel. 

The  ch'essing  of  the  wound  requires  no  especial  technique.  The  cavity  of 
the  wound  is  flushed  with  an  aseptic  solution  or  wiped  dry;  loose  clots  are 
removed,  and  all  bleeding  points  are  arrested.  The  margins  of  the  wound 
are  carefully  united  with  silkworm-gut  sutures,  and  drainage  is  employed  at 
the  dependent  parts.  The  walls  of  the  wound  are  pressed  together  and 
dead  spaces  eliminated  by  catgut  sutures,  and  sponge  pressure  carefully 
adjusted  and  equalized  by  a  thick  covering  of  absorbent  cotton  held  in  place 
with  bandages.  If  the  bandages  are  applied  too  tightly  much  discomfort 
will  follow.  A  mild  pharyngitis,  attended  with  profuse  expectoration  of 
mucus,  often  occurs,  as  in  other  operations  on  the  neck,  at  the  sides,  and  at 
the  median  line. 

The  after-treatment  is  of  a  routine  character.  The  head  is  kept  flexed 
as  much  as  comfort  will  permit,  and  the  dressings  are  changed  to  conform 
with  needed  cleanliness.  The  drainage  is  removed  after  a  day  or  two.  The 
food  should  be  bland  and  nutrient,  and  fresli  air  freely  provided.- 

The  Results. — The  40-per-cent  death  rate  of  forty-five  years  ago  was 
reduced  to  21  before  1871,  and  to  11  per  cent  before  1877.  In  1895  Kocher 
reported  1,000  cases  of  benign  goitre  operated  on  by  himself,  with  an  opera- 
tion death  rate  of  1  per  cent.  To  this  list  can  now  be  added  700  others,  of 
which  Kocher  performed  550  and  his  assistants  the  remainder.  The  last 
600  of  this  series  includes  18  malignant  and  15  exophthalmic  cases,  and  still 
the  average  death  rate  is  but  1  per  cent.  Krunlein  and  Sulzcr  report  200 
and  144  cases  respectively  without  a  death.  A  2-per-cent  rate  of  mortality 
is  now  a  fair  estimate  of  the  results  of  experienced  hands  in  benign  cases. 
The  outlook  in  malignant  cases  is  gloomy.  Kocher's  operative  death  rate 
is  33.33  per  cent.  The  average  duration  of  life  is  about  six  months  (Orcel)  ; 
84  per  cent  die  in  six  and  60  per  cent  in  eight  weeks  (Rotter).  In  exoph- 
thalmic goitre  the  rate  of  mortality  from  operation  is  well  shown  by  the 
cases  collected  by  Starr.  In  190  cases  74  were  cured,  45  improved,  3  unim- 
proved, and  23  died  from  the  operation.  The  remaining  45  not  stated. 
The  mortality  rate  varies  from  7  (Kinnicutt)  to  12  or  15  per  cent,  depending 
on  the  judgment  and  operative  skill  of  the  surgeon. 

Wounds  of  the  Neck. — Incised,  stab,  and  gunshot  wounds  of  the  neck  are  of 
not  infi'equent  occurrence.  Incised  wounds  happen  of  tenest  because  of  suicidal 
attempts.  The  location  and  extent  of  the  incision  modify  its  severity.  If  at 
the  front  and  above  the  hyoid  bone,  the  base  of  the  tongue  may  be  involved, 
if  through  the  thyroid  space,  the  epiglottis  and  pharynx  (Fig.  1276),  if 
lower,  the  larynx  and  trachea  respectively  may  be  involved.  Incision  through 
the  thyro-hyoid  space  occurs  most  frequently.  If  the  wound  be  superficial, 
but  little  harm  may  arise ;  if  deep,  free  division  of  the  air  passage  and  per- 


OPERATIONS   ON    TIIH    Nl-X'K.  1097 

haps  of  important  vessels  on  cither  side  is  followed  more  or  less  promptly  by 
deatii  from  hti'morrluige  or  asphyxia,  unless  relieved.  Deep  wounds,  involv- 
ing the  spaces  immediately  above  and  below  the  hyoid  bone,  incite  suffoca- 
tion from  the  closure  of  tiie  larynx  by  the  down-falling  of  the  base  of  the 
divided  tongue  and  of  the  divided  epiglottis  respectively.  Inflowing  blood 
is  an  important  element  of  immediate  and  remote  danger  in  all  instances  of 
air-passage  involvement,  causing  infection  in  the  first  and  septic  iuilamma- 
tion  of  the  lungs  and  bronchi  iu  the  latter  instance.  (Edema  of  the  glottis 
and  emphysema  of  the  connective  tissue  are  common  and  important  com- 
lilioations  of  these  wounds,  tlie  former  happening  most  frequently  with  upper 
and  the  latter  with  lower  involvements  of  the  air  passages.  The  importance 
of  gunshot  and  stab  wounds  relates  to  the  direction  and  extent  of  injury. 
The  important  vessels  and  nerves,  the  a?sophagus,  the  trachea,  and  even  the 
jileural  cavity  and  lung  itself,  may  be  involved  in  these  injuries. 

Fracture  of  the  larynx  and  hyoid  bone  may  result  from  direct  blows  and 
from  manual  choking.  These  injuries  may  so  deform  and  cripple  the  parts 
as  to  threaten  suffocation  iu  the  former,  and  cause  much  pain  and  annoy- 
ance in  the  latter  instance. 

The  Treatment. — The  treatment  is  regulated  by  the  urgency  of  the  symp- 
toms. Severe  ha?morrhage  and  asphyxia  demand  instant  arrest  of  bleeding, 
the  removal  of  obstruction,  and  the  performance  of  tracheotomy,  if  then 
required.  When  time  will  permit,  thorough  asepsis  should  be  practiced. 
In  wounds  involving  the  air  passages  the  arrest  of  bleeding  is  of  double  sig- 
nificance, preventing  the  entrance  of  blood  into  the  respiratory  passages  as 
well  as  the  loss  to  the  patient.  Temporary  tracheotomy  is  usually  required 
iu  wounds  of  the  trachea,  the  larynx,  and  the  pharynx,  especially  the  latter 
two,  in  order  that  the  danger  incurred  by  the  sudden  advent  of  cpdema  of 
the  glottis  may  be  forestalled.  Wounds  of  the  trachea  may  be  closed  with 
catgut  at  once  and  tracheotomy  omitted.  In  wounds  of  other  kinds  the  tube 
may  be  inserted  at  the  seat  of  injury  or  through  a  high  tracheotomy,  if  the 
location  of  the  wound  permits.  In  wounds  involving  the  pharynx,  trache- 
otomy is  often  advisable  as  the  best  means  of  avoiding  the  septic  exposures 
arising  from  discharges  provoked  by  food  contact,  as  well  as  the  dangers  of 
oedema  of  the  glottis.  Tracheotomy  permits  of  careful  cleansing  and  closure 
of  the  original  wound  in  many  instances.  In  wounds  of  the  oesophagus, 
infiltration  of  the  deep  tissues  of  the  neck  from  swallowing  food  and  fluid 
may  happen  before  the  existence  of  an  injury  is  suspected.  In  stab  and 
gunshot  wounds  of  the  trachea  extensive  and  dangerous  emphysema  may 
arise,  requiring  tracheotomy  and  free  incision  for  relief.  A  gunshot  wound 
of  the  neck,  passing  contiguous  to  but  not  involving  the  trachea,  and  enter- 
ing the  lung,  may  cause  extensive  emphysema  and  otherwise  simulate  in 
all  important  respects  a  wound  of  the  trachea.  (Esophageal  wounds  should 
be  exposed  at  once,  cleansed,  and,  if  clean  cut,  sutured.  Ragged  wounds, 
howsoever  inflicted,  should  be  treated  by  drainage  and  packing.  In  no 
instance  is  it  wise  to  completely  close  a  wound  in  case  of  oesophageal  involve- 
ment (page  596),  because  the  uncertainty  of  union  of  the  tube  renders  pri- 
mary closure  unsafe.     Wounds  of  the  tongue  and  epiglottis  are  sewed  care- 


1098 


OI'KKA'I'IVE  SURGERY. 


fully  at  once,  the  divided  borders  of  the  mucous  membrane  of  the  pharynx 
being  closely  apposed  by  sewing  before  the  more  superficial  structures  are 
united.     In  all  suitable  instances  wounds  of  the  neck  should  be  carefully 

closed.  The  divided  borders  of 
the  muscles  and  gaping  structures 
sliould  be  united  with  sutures  to 
secure  prompt  and  effective  union, 
thus  eliminating  dead  spaces.  Af- 
ter suture  of  the  soft  parts  the  neck 
is  flexed,  and  sufKcient  pressure  is 
applied  to  cause  still  further  the 
approximation  and  retention  essen- 
tial to  tiie  prevention  of  dead 
spaces  and  to  good  union.  Drain- 
age should  be  employed  only  in 
the  instance  of  suspected  infection. 
Fixed  position  of  the  neck,  clean- 
liness, alimentation  by  the  bowel 
for  a  day  or  so  in  case  of  pharyn- 
geal wound,  followed  by  feeding 
by  the  stomach  tube,  are  impor- 
tant measures  of  treatment.  If  the 
head  be  lowered  for  the  first  two 
or  three  days,  an  increase  of  blood 
in  the  brain  and  the  flow  of  the 
discharges  away  from  the  Avound 
will  be  favored.  Tlie  tracheal, 
the  oesophageal,  and  laryngeal  se- 
quels should  be  treated  as  necessity 
demands. 

Abscess  and  Phlegmon  of  the 
Neck. — Abscess  and  phlegmon  of 
the  neck  located  in  the  sublingual 
(Lud wig's  angina),  submaxillary, 
and  jiarotid  regions,  also  at  tlie  an- 
terior and  lateral  cervical  regions 
from  glandular  involvement,  not 
infrequently  occur.  In  each  in- 
stance early  relief  should  be  sought 
b}'^  free  incision. 

The  awaiting  the  presence  of 
fluctuation  while  encouraging  its 
appearance    by    poultices,    etc.,    is 


Fig.  1294.— Arrangement  ot  iIh'  (li'c|)  cervical 
fascia,  muscles,  vessels,  nerves,  etc.,  as  shown 
by  transverse  section  on  level  with  sixth  cer- 
vical vertebra,  a.  Anterior  jugular  vein.  h. 
Sterno-hyoid  muscle,  c.  Omo-hyoid  muscle. 
d.  External  jugular  vein.  e.  Internal  jugu- 
lar vein.  /.  Common  carotid  arterv.  q. 
Pnciiinogastric  nerve.  /(.  Vertebral  vessel's. 
i.  Symjiatiietic  nerve,  j.  Descendens  hypo- 
glossi  nerve,     k.  Recurrent  larvngeal  nerve. 


often  fraught  with  grave  dangers 
from  purulent  and  serous  infection,  inflltration  of  the  deep  tissues  of  the 
neck,  and  oedema  glottidis,  especially  in  those  cases  located  below  the  infe- 
rior maxilla.      Extensive  sloughing  of  the  connective  tissue  of   the  neck, 


urKKATlUNS   UN   THE   XKCK. 


lU'J'J 


attended  with  f»i'tid  gas,  luive  been  seen  by  the  writer.  The  relief  of  tlie 
tension,  prevention  of  sloughing,  and  extensive  infiltration  of  morbid  j>ro- 
duots,  even  into  the  thorax,  reijuires  early  and  decided  action.  Also  the 
liability  to  sudden  and  fatal  uidenia  of  the  glottis  demands  the  exercise  of 
the  forethought  necessary  to  meet  and  relieve  the  complication  at  once  by 
broiicliotdiny  ([)a;j;i'  (;(•,(;). 

Retropharyngeal  Abscess. — Retropharyngeal  abscess  is  not  an  infrequent 
affection,  especially  in  children.  Phlegmonous  inflammation  of  the  pharvn- 
geal  tissues,  the  softening  of  diseased  lymphatic  glands,  and  caries  of  the 
bodies  of  cervical  vertebrae  are  frequent  causes  of  this  variety  of  abscess. 

The  AiKiloinical  Points. — The  relations  of  the  various  extensions  of  the 
deep  cervical  fascia  to  the  esophagus,  pharynx,  and  the  other  deep  struc- 
tures of  the  neck  (Fig.  1:^94),  together  with  the  fact  that  the  lower  limit 
of  the  pharynx  corresponds  to  the  intervertebral  disk  of  the  fifth  and  sixth 
cervical  vertebra?,  and  the  liability  of  the  extension  by  burrowing  of  post- 
pharyngeal suppuration  into  the  thorax,  are  individually  and  collectively 
important  items  ((Jerster).  Retropharyngeal  abscess  may  be  opened  inter- 
nally through  the  i)harynx  and  externally  through  the  neck  at  two  situations. 

The  evacuation  through  the  mouth  is  not  advisable,  except  in  the  instance 
of  small  collections  of  pus  dependent  upon  transient  causes.  The  chronic 
discharge  of  pus  into  the  pharynx  is  objectionable  from  nearly  every  stand- 
point, and  especially  when  the  disease  is  thus  protracted  by  inefficient  drain- 
age and  inadequate  cleanliness.  If  it  be  determined  to  evacuate  the  abscess 
through  the  pharynx,  cleanse  the  part  thoroughly,  place  the  j^atient  on  the 
back  in  a  good  light,  cocainize  the  mucous  membrane,  fasten  the  jaws  apart, 
seize  the  tongue  and  draw  it  forward.  The  end  of  the  left  index  finger  is 
placed  against  the  prominent  fluctuating  point, 
and  the  patient  is  caused  to  inspire  deeply.  A 
sharp-pointed  bistoury,  its  blade  protected,  ex- 
cept at  the  point,  with  adhesive  plaster,  is  then 
(Fig.  734:,  G)  carried  along  the  finger  into  the 
abscess,  and  an  opening  is  made  downward 
or  upward,  according  to  the  location  of  the 
point  of  greatest  prominence,  half  an  inch  or 
so  in  length  (Fig.  129.5).  As  the  fluid  escapes, 
the  finger  is  withdrawn,  and  the  patient  turned 
over  and  caused  to  expire  forcibly,  so  as  to 
clear  the  throat  of  the  discharge.  Sponging 
with  sterilized  water,  to  remove  the  pus  and 
promote  cleanliness,  is  practiced  from  time  to 

time  until  healing  takes  place.  In  every  instance  when  extended  suppura- 
tion is  anticipated,  the  evacuating  incision  should  be  made  from  without, 
behind,  or  in  front  of  the  sterno-mastoid  muscle. 

Chiene's  Method. — Cldene  made  an  incision  from  the  mastoid  process 
downward  along  the  posterior  border  of  the  sterno-mastoid  muscle  the 
proper  distance  through  the  integument  and  fascia,  drew  the  posterior  bor- 
der of  the  muscle    forward  and  passed  in  front  of  the  scalenus  anticus, 


Fig.  129.J. — Opening  a  retro- 
pharyngeal abscess. 


1100  OPERATIVE   SURGERY. 

(Fig.  1:294:)  behind  the  deep  vessels  and  the  longus  colli  to  the  retropharyn- 
geal space,  by  means  of  blunt  dissection. 

This  plan  of  evacuation  is  a  comparatively  simple  one,  as  no  important 
structures  intervene.  The  course  is  direct,  the  drainage  quite  dependent, 
and  any  resulting  disfigurement  is  at  tlie  side  rather  than  in  the  front  of 
the  neck. 

Buckhardt's  Method. — Buckliardt  made  an  incision  at  the  anterior  bor- 
der of  the  sterno-mastoid  muscle,  at  the  level  of  the  larynx,  through  the  skin 
and  platysma,  and  reached  the  vessels  of  the  thyroid  body,  which  he  pushed 
aside.  The  carotid  sheath  was  quickly  exposed  and  drawn  outward  along 
with  its  contents  by  means  of  a  hook.  The  jjrevertebral  fascia  covering 
the  longus  colli  (Fig.  1294)  was  quickly  opened,  and  the  prevertebral  space 
promptly  gained  by  blunt  dissection  directed  transversely  inward  across  the 
muscle.  The  only  vessels  directly  in  the  course  of  this  dissection  were  a 
small  subcutaneous  vein,  which  was  tied  between  two  ligatures,  and  the 
thyroid  vessels,  which  were  pushed  aside.  The  route  by  the  latter  method 
is  somewhat  shorter,  and  the  field  of  disease  is  more  easily  exposed.  How- 
ever, the  drainage  is  less  free  and  the  disfigurement  more  prominent  than 
in  the  former. 

The  Remarks. — Tuberculous  products,  foreign  bodies,  and  diseased  bone 
should  be  removed  carefully,  suitable  drainage  introduced,  cleanliness 
secured,  and  repair  encouraged  by  the  recognized  antiseptic  means. 

The  Results. — Little  or  no  danger  arises  from  the  operation  if  conducted 
antiseptically  and  with  care.  The  final  outcome  is  dependent  on  the  nature 
of  the  disease  causing  the  abscess. 

The  Removal  of  Diseased  Cervical  Lymphatic  Glands.— The  devious  and 
unforeseen  relations  that  exist  between  diseased  cervical  glands  and  the 
important  superficial  and  deep  structures  of  the  neck,  invest  their  removal 
with  a  sense  of  responsibility  that  often  begets  a  strong  feeling  of  uncer- 
tainty as  to  the  wisdom  of  the  attempt  in  many  instances.  Apparently 
simple  cases  often  become,  as  the  operation  progresses,  difficult  and  com- 
plex, and  sometimes  even  dangerous  of  execution.  It  is  wise,  therefore,  that 
the  patient  or  the  friends  be  given  at  the  outset  a  quite  definite  idea  of  the 
•uncertainties  that  too  often  are  a  serious  part  of  the  procedure.  At  all 
events,  they  ought  not  to  be  permitted  to  regard  the  operation  as  trivial. 
The  glands  may  be  more  or  less  firm  and  independently  encapsulated 
or  broken  down  and  adherent  to  each  other.  Caseous  and  iniiammatory 
products  may  take  the  place  of  or  mingle  with  definite  gland  structure. 
The  superficial  and  deep  series  of  glands  may  be  affected  independently 
of  each  other,  but  usually  they  are  diseased  conjointly,  although  in  an 
irregular  and  often  unexpected  manner.  An  easily  removable  diseased 
superficial  series  may  communicate  freely  with  a  deep  one  that  is  intri- 
cately associated  with  important  structures. 

The  Anatomical  Points. — Before  attempting  the  removal  in  pronounced 
cases,  the  course  and  relation  of  the  superficial  and  deep  nerves  and  vessels 
should  be  reviewed.  The  superficial  branches  of  the  cervical  plexus  are 
especially  exposed  to  division.     The  cervico-facial  branch  of  the  facial  nerve 


OPERATIONS   ON    TIIP:    NECK. 


llt»l 


and  its  terniiuiil  bninches  mkiv  bu  injured,  causing  objectionable  paralysis  of 
the  lower  lip.  The  relation  of  the  spinal  accessory  to  the  upper  end  of  the 
sterno-inastoid  is  of  great  importance.  The  relation  of  the  superficial  and 
deep  glands  with  the  sterno-inastoid  muscle,  and  the  latter  with  the  deep 
glands  of  the  neck,  are  matters  of  great  significance.  Any  good  text-book 
on  anatomy  will  illustrate  forcibly  these  important  features.  The  presence 
and  location  of  the  lymphatic  ducts  should  not  escape  attention. 


Fig.  1296. — The  instruments  employed  in  removal  of  diseased  cervical  lymphatic  glands. 

a.  Scalpels,  large  and  small,  h.  Forcipressure.  curved  and  straight,  c.  Forceps,  dis- 
secting and  mouse-tooth,  d.  Scissors,  short  blunt-pointed  straight,  and  curved  on 
the  flat.  e.  Probe.  /.  Blunt  dissectors,  g.  Sharper  blunt  dissector,  h.  Aneurism 
needle.  ;'.  Grooved  director,  j.  Small  scoop.  A-.  Needles  and  catgut.  I.  Horsehair. 
m.  Single-  and  two-tined  tenacula.  n.  Small  hooked  and  blunt-pointed  retractors. 
Wipers,  ligatures,  drainage  agents,  large  retractors,  and  ample  gauze  and  plaster-of- 
Paris  bandagfes  are  needed. 


Tlie  incisions  for  the  removal  vary  in  accordance  with  the  situation  and 
extent  of  the  glandular  involvement,  the  importance  of  the  contiguous  anat- 
omy, and  the  liability  to  operative  disfigurement.  The  transversely  directed 
skin  fold  at  the  upper  part  of  the  neck  suggests  the  site  of  an  incision  to 
obviate  deformity  in  the  removal  of  glands  located  opposite  to  the  hyoid 
bone  and  anterior  to  the  sterno-mastoid  muscle.  The  glands  in  the  lower 
part  of  the  posterior  triangle  can  be  well  approached  through  a  similar 
incision  at  that  situation.  At  other  situations  oblique  incisions  arranged 
to  conform  to  the  anterior  or  posterior  border  of  the  sterno-mastoid  are 
advisable.  The  S-shaped  incision  of  Hartley  (Fig.  1297),  employed  as  a 
whole  or  in  part,  as  circumstances  require,  is  a  commendable  one.     In  all 


1102  OPERATIVE  SURGERY. 

instances  the  incision  should  be  made  sufficiently  free  to  afford  ample  room. 
Safety  of  execution  should  not  be  exchanged  for  cosmetic  result.  The 
patient  should  be  placed  upon  the  back,  with  the  shoulders  raised  and  the 
head  turned  to  the  opposite  side.  A  good  light,  plenty  of  time  and  assist- 
ance, and  aseptic  detail  should  be  at  the  command  of  the  operator.  Chlo- 
roform or  A.  C.  E.  mixture  should  be  given  to  avoid  congestion  of  the  ves- 
sels, unless  contraindicated. 

The  Operation  (Treves). — Make  a  free  incision  along  the  selected  line 
through  the  skin,  platysma,  and  fascia,  avoiding  the  division  of  the  super- 
ficial nerves,  if  possible;  expose  and  free  the  sterno-mastoid  muscle  and 
hold  it  aside  with  retractors  when  in  the  field  of  operation ;  divide  the  mus- 
cular fibers  to  a  limited  extent,  and  then  only  when  necessary ;  divide  the 
deep  fascia  and  expose  the  capsules  of  the  enlarged  glands ;  turn  out  the 
glands  with  the  handle  of  the  scalpel  or  a  similarly  shaped  implement,  if 
they  be  non-adherent;  if  adherent,  attack  the  aggregation  at  the  point  least 
firmly  fixed,  keeping  close  to  the  capsules  throughout  the  dissection,  and 
removing  adherent  portions  of  the  same ;  dissect  out,  rather  than  tear  out 
a  mass  of  tissue,  as  the  latter  procedure  ruptures  the  connective  vessels, 
the  nerves,  and  also  the  capsules,  smearing  the  tissues  with  the  disorganized 
gland  structure;  relax  and  examine  constricting  bands  of  tissue  before  divi- 
sion, as  they  may  contain  vessels,  nerves,  etc.,  and  when  in  doubt  regarding 
the  presence  of  the  former  divide  the  tissue  between  constricting  agents ; 
isolate  torn  vessels,  and  tie  above  and  below  the  rent  with  catgut ;  search 
carefully  for  isolated  and  deep-seated  glands,  leaving  none  behind,  unless 
their  removal  as  a  whole  begets  unwarranted  danger,  and  in  such  as  these 
divide  the  capsule  and  dig  away  the  contents,  removing  the  capsule  after- 
ward, if  practicable ;  flush  out  the  wound  with  an  antiseptic  solution,  remov- 
ing blood  clots  and  arresting  all  bleeding  j)oints ;  close  the  wound  with  deep 
and  superficial  sutures,  eradicating  all  dead  spaces;  introduce  drainage  in 
deep  wounds,  those  with  lacerated  borders,  and  in  any  in  which  diseased 
tissue  remains  behind ;  apply  antiseptic  dressings  with  overlying  sponges 
for  compression,  bandaging  them  as  firmly  in  place  as  the  respiratory  and 
circulatory  functions  of  the  neck  of  the  imtient  will  permit. 

The  Precautions. — Avoid  rupturing  the  diseased  glands,  as  consequent 
infection  of  contiguous  freshened  surfaces  may  follow.  In  such  instances 
careful  cleansing  should  be  practiced  at  once.  Incautious  attention  and 
indifference  to  anatomical  details  during  removal  of  these  glands  leads  to 
unnecessary  division  of  the  superficial  nerves,  especially  the  superficial  cer- 
yical.  This  nerve  passes  across  the  neck  on  either  side,  nearly  opposite 
the  thyroid  cartilage.  The  spinal  accessory  is  exposed  in  operations  at  the 
upper  part  of  the  posterior  triangle,  but  can  be  readily  recognized,  when 
irritated,  by  the  causing  of  contractions  of  the  muscles  it  supplies.  The 
phrenic,  pneumogastric,  recurrent  laryngeal,  descendens  hypoglossi,  the  pri- 
mary cords  of  the  brachial  plexus,  and  the  cervical  sympathetic  nerves  are 
in  but  little  danger  except  in  extensive  involvement  of  the  deep  series  of 
glands,  or  during  removal  of  deep-seated  growths  of  a  different  nature. 
Tinder   similar    circumstances,   the   apices   of   the   pleural   cavities — which 


OI'IIUA'I'IOXS   OX    Till-:    N'Kf'K.  IKC] 

extend  ahovo  the  (irst  rib  at  either  side  to  the  body  of  tlic  seventh  cervical 
vertebra,  and  lii^^hcr  in  the  fetnale  thiin  in  the  nude — may  be  invaded.  Tiie 
riirlit  and  left  lymphatic  ducts  are  also  endangered  by  dissection  at  these 
situations.  The  entrance  of  air  into  the  veins  is  a  danger  to  be  apprehended 
here.  The  prevention  and  treatment  is  considered  already  on  page  105. 
"  Keep  close  to  the  capsule ;  make  no  cut  in  the  dark  ;  be  chary  of  cutting 
tissues  which  are  only  seen  when  put  fully  upon  the  stretch,"  are  wise  admo- 
nitions of  Treves. 

The  effects  of  division  of  the  recurrent  laryngeal,  sympathetic,  and  com- 
mon motor  nerves  of  the  neck  are  well  understood,  and  need  no  special 
mention.  The  effect  of  division  of  one  or  both  phrenic  nerves  is  compara- 
tively so  well  illustrated  by  the  outcome  in  cases  of  crushing  attendant  on 
fracture  of  the  cervical  vertebrae  as  to  need  only  the  admonition  which  the 
latter  teach  to  impress  the  importance  of  the  maintenance  of  their  structural 
integrity.  Kegarding  the  pneumogastric  in  this  connection  one  can  do  no 
better  than  to  quote  the  conclusion  of  Park^  uttered  in  1895,  after  an  able 
consideration  of  recorded  cases :  "  Nevertheless,  the  j^reponderance  of  testi- 
mony is  in  favor  of  the  comparative  safety  of  attacking  this  nerve  when 
involved  in  disease,  and  when  too  much  other  disturbance  is  not  necessitated 
by  the  condition  which  has  caused  the  operation."* 

If  injury  of  the  thoracic  duct  be  detected  in  time,  and  tlie  seat  of  the 
wound  can  be  found,  repair  may  be  made  by  means  of  interrupted  sutures 
or  by  implantation  (page  854),  as  circumstances  require.  Usually  a  knowl- 
edge of  the  injury  occurs  too  late  for  the  purpose,  and  even  when  favorably 
recognized,  detection  of  the  breach  in  the  duct  may  not  be  possible.  Under 
the  circumstances  direct  pressure  with  gauze  compresses  is  the  suitable  and 
usually  successful  treatment  in  both  instances. 

The  Remarks. — The  natural  intimate  association  of  the  lymphatic  struc- 
tures with  the  veins  bespeaks  the  difficulty  of  the  removal  of  the  former 
when  diseased.  The  compressed  veins  become  changed  in  their  normal 
aspects,  and  therefore  are  often  divided  in  spite  of  the  greatest  caution. 
When  a  vein  can  not  be  separated  from  a  lymphatic  enlargement,  it  should 
be  sacrificed,  except,  perhaps,  in  the  instance  of  the  internal  jugular,  when 
the  gland  should  be  removed  piecemeal  if  need  be.  Excision  (page  179)  of 
a  portion  of  this  vein  between  two  ligatures  is  justifiable  when  it  is  torn  or 
traverses  a  malignant  growth.  Xormal  veins  of  a  minor  size  often  resemble 
the  hu'gest  ones  when  compressed  by  glandular  enlargements  and  malignant 
growths.  The  sterno-mastoid  muscle  should  not  be  divided,  if  possible  to 
avoid  it,  as  marked  deformity  may  follow  imperfect  union  of  the  divided  ends. 

Hartley's  Method. — Hartley  devised,  some  time  since,  the  following  ingen- 
ious plan  of  approach  to  diseased  glands  of  the  neck.  The  operative  con- 
venience and  the  curative  and  cosmetic  outcome  of  the  plan  are  such  as  to 
commend  its  employment.  The  follow^ing  description  is  quoted  from  Stim- 
son's  valuable  work  on  operative  surgery,  and  has  the  additional  Avorth  due 
to  Hartley's  personal  revision. 

*  Transactions  of  the  American  Surgical  Association,  vol.  xiii. 


1104 


OPERATIVE  SURGERY. 


71ie  Operation. — "The  incisiou  is  S-shapcd  (Fig.  1297),  and  involves 
only  the  skin,  subcutaneous  tissue,  and  fascia ;  starting  below  the  chin  it 
jiasses  in  a  curve  downward  and  backward  to  the  hyoid  bone,  then  up 
beliind  the  angle  of  the  jaw  to  near  the  lobule  of  the  ear,  whence  it  sweeps 
down  along  the  anterior  border  of  the  trapezius,  forward  over  the  sterno- 
mastoid,  and  downward  and  backward  again  to  terminate  above  the  middle 

of  the  clavicle  (^,  c,  d).  The  flaps 
thus  formed  are  dissected  up,  ex- 
posing nearly  the  whole  length 
of  the  steruo-mastoid,  and  the 
latter  is  cut  transversely  near  its 
center  and  the  ends  reflected, 
care  being  taken  not  to  injure 
the  spinal  accessory  nerve  above. 
The  point  where  the  muscle  is 
divided  must  not  be  in  the  line 
of  the  cutaneous  incision,  but 
under  the  middle  of  one  of  the 
flaps,  preferably  the  upper  (a). 
The  great  vessels  are  thus  ex- 
posed from  the  mastoid  process  to 
the  clavicle,  and  the  operator  can 
excise  the  adherent  and  diseased 
glands,  and  avoid  injui-y  to  the 
adjacent  important  structures. 
At  the  close  of  the  operation  the  divided  ends  of  the  sterno-mastoid  are 
united  with  catgut,  the  flaps  replaced  and  loosely  sutured  in  position,  and 
drainage  provided  for  in  the  most  dependent  angles. 

This  large  incision  is  only  used  when  the  glands  in  tlie  superior  and 
inferior  carotid  and  submaxillary  triangles  are  involved  simultaneously.  For 
less  extensive  disease  the  upper  or  lower  flap  may  be  employed  alone ;  or  one 
may  be  fashioned  with  a  pedicle  in  a  position  the  reverse  of  that  shown  in 
the  figure.  The  incision  for  a  single  flap  should  approximately  correspond 
to  the  circumference  of  the  tumor,  which  is  then  exposed  in  its  entirety  by 
division  of  the  sterno-mastoid  below  the  point  where  it  is  entered  by  the  spinal 
accessory  nerve.  The  flap  consists  of  skin,  subcutaneous  tissue,  platysma, 
and  fascia. 

The  After-treatment. — The  after-treatment  in  these  operations  consists 
in  securing  the  complete  rest  consistent  with  the  proper  cleanliness  of  the 
wound  by  an  overlying  plaster-of- Paris  bandage,  or  by  sand  bags  at  either 
side  of  the  head  for  a  week  or  two.  Fluids  should  be  given,  and  move- 
ments of  the  lower  jaw  interdicted.  The  drainage  should  be  removed  in  a 
day  or  two,  except  wlien  diseased  products  are  present.  The  sutures  are 
taken  out  in  seven  or  eight  days;  the  buried  ones,  of  course,  remain. 

The  Results. — In  128  cases  operated  on  by  Billroth,  91  healed  by  primary 
union,  2o  suppurated,  and  erysipelas  developed  in  b.  In  49  the  final  result 
could  not  be  obtained.     In  24  per  cent  no  recurrence  appeared  in  three  and 


Fig.  1297. — The  removal  of  diseased  cervical  lym- 
phatic glands,  Hartley's  method,  a.  Point 
of  division  of  the  sterno-mastoid  muscle. 
h,  c,  d.  Line  of  incision. 


orKKATlON'S   ON    TIIK    NKCK.  ly^t^ 

a  lull f  years.  Ldcnl  relapso  huppened  in  14  per  cent,  iiiid  in  1  per  cent  at 
})oints  distant  from  the  seat  of  opeiation.  In  16  cases  the  internal  jugular 
was  tied. 

Branchial  Cysts. —  Branchial  cysts  are  of  congenital  origin  and  should 
be  removed  as  early  in  their  history  as  j)racticable.  Their  frequent  intimate 
association  with  the  important  deep  structures  of  the  neck  invest  their  treat- 
ment with  especial  concern.  IS'ot  infrequently  a  somewhat  superficial  cyst 
of  this  nature  is  connected  deei)ly  by  means  of  a  long,  narrow,  devious  tract, 
the  discovery  and  eradication  of  which  is  necessary  to  a  final  cure.  The 
steps  of  the  operative  removal  of  these  morbid  developments  differ  in  no 
essential  respect  from  those  directed  to  the  treatment  of  diseased  glands. 
The  frequent  greater  profundity  of  the  former  is  offset  by  the  extensive 
morbitl  changes  of  the  latter,  so  far  as  operative  technique  is  concerned. 
The  introduction  of  a  probe  along  the  channel  to  the  seat  of  origin  is  often 
advantageous  in  the  treatment  of  this  variety  of  cases.  In  the  instance  of 
removal  from  the  neck  of  other  tumors  than  the  special  ones  already  con- 
sidered, the  rules  of  technique  applicable  to  the  latter  can  be  satisfactorily  ap- 
plied to  the  removal  of  the  former  class.  Briefly  stated,  free  exposure  of  the 
growth  through  an  incision  best  suited  to  the  purpose ;  the  removal  by  cau- 
tious blunt  dissection,  attended  with  prompt  control  of  bleeding  points;  the 
prevention  of  air  thrombosis;  and  the  preservation  of  important  structures. 

The  Extirpation  of  the  Parotid  Gland. — The  complete  removal  of  this 
gland  is  a  most  ditffcult  operation,  especially  when  its  relations  are  changed 
by  a  malignant  growth  implicating  its  structure. 

The  Anatomical  Points. — The  space  in  which  this  gland  is  located  is 
deep,  narrow  above,  broader  below,  and  modified  by  the  movement  of  the 
lower  jaw.  It  is  bounded  above  by  the  zygoma ;  below,  by  a  line  extending 
from  the  angle  of  the  inferior  maxilla  backward  to  the  sterno-mastoid  mus- 
cle ;  in  front,  by  the  posterior  border  of  the  ramus  of  the  jaw ;  behind,  by 
the  external  auditory  meatus  and  mastoid  process  (Fig.  1;298).  The  gland  is 
separated  from  the  submaxillary  region  by  the  stylo-maxillary  ligament,  and 
from  the  deeper  tissues  by  the  styloid  process,  and  the  ligaments  and  muscles 
connected  with  it.  Prolongations  of  considerable  size  extend  from  its  deep 
surface  inward,  one  in  front  of  and  the  other  behind  the  styloid  process,  the 
former  passing  beiiind  the  mastoid  process  and  sterno-mastoid  muscle,  the 
latter  to  the  back  part  of  the  glenoid  fossa.  The  external  carotid  artery 
passes  through  the  gland  from  below  upward,  dividing  into  its  terminal 
branches  before  its  escape.  Superficial  to  this  artery  there  is  a  venous 
trunk  formed  by  the  union  of  the  temporal  and  internal  maxillary  veins ; 
to  this  trunk  the  internal  jugular  is  connected  by  a  small  branch  that  passes 
through  the  gland  structure.  The  facial  nerve  and  its  branches  traverse  the 
gland  from  behind  forward,  and  receive  a  communicating  branch  from  the 
great  auricular  in  its  substance.  Immediately  beneath  the  floor  of  the  space 
lie  the  internal  carotid  artery  and  internal  jugular  vein,  along  with  the  spi- 
nal accessory,  glosso-pharyngeal,  and  pneumogastric  nerves.  Lymphatic 
glands  lie  over  the  parotid  and  are  present  within  it,  and  their  enlargement 
may  be  mistaken  for  that  of  the  gland  itself. 


1106 


OPERATIVE   SURGERY. 


llie  Contrai7idicatio7is  to  Extivpatwji. — Iininobility  of  tlie  tumor  and 
a  malignant  growth  implicating  the  structure  of  the  gland  may  be  regarded 
as  strong  contraindications  to  operation. 

The  Operation. — Place  the  patient  upon  a  suitable  table  in  a  good  light, 
with  the  shoulders  elevated  and  the  head  turned  to  the  opposite  side.  Make 
an  incision  from  the  zygoma  downward  along  the  central  line  of  the  tumor 
to  its  lower  border.  If  necessary,  this  one  can  be  supplemented  by  one  or 
more  extending  from  it  at  right  angles.     The  integumentary  flaps  are  freely 


Fig.  1298. — The  surgical  anatomy  of  the  thyroid  gland. 

reflected  to  expose  the  growth.  The  tumor  should  be  raised  from  below 
upward,  and  held  by  a  volsella.  This  will  raise  the  external  carotid  from  its 
bed,  when  it  should  be  isolated,  tied  between  two  ligatures,  and  divided. 
The  vessels  that  enter  or  escape  from  the  tumor  at  this  point  should  be 
treated  in  the  same  manner  (Fig.  1298).  The  tumor  can  now  be  raised 
upward,  and  its  separation  from  the  deeper  tissues  continued  by  means  of 
the  fingers  or  handle  of  the  scalpel ;  the  former  are  the  better.  The  vessels, 
as  they  appear  in  the  course  of  the  dissection,  are  isolated  and  cut  between 
two  ligatures. 

The  separation  of  the  growth  from  the  floor  of  the  space  must  be  done 
gently  and  with  great  caution  on  account  of  the  contiguity  of  the  internal 
jugular  vein  and  the  other  important  vessels,  and  the  nerves  located  there, 
which,  if  the  growth  be  a  large  one,  will  be  pressed  upon  by  it,  and  may  have 
become  adherent  to  it.  It  is  scarcely  possible  to  avoid  division  of  the  facial 
nerves  if  the  growth  be  compact.  If  it  be  soft  and  spongy,  the  integrity  of 
the  nerve  may  be  preserved  by  a  careful  use  of  the  fingers  or  director.     The 


OIMIKA'I'IONS    ON    Till':    NKCK.  1107 

upper  cxtrt'iuity  of  the  ghiiid  is  last  reniovutl.  This  step  of  the  operation  is 
necessarily  attended  witli  considerable  haemorrhage,  which  is,  however,  easily 
controlled.  After  the  removal,  unite  the  flaps,  establish  drainage,  and  dress 
nntiseptically.  During  the  dissection,  room  can  be  gained  by  causing  the 
patient  to  open  the  moutli.  Some  tumors  of  large  size,  without  adhesions,  are 
more  easily  removed  than  small  adherent  tumors.  "When,  as  one  approaches 
the  large  vessels,  the  adhesions  become  more  resistant,  great  caution  should 
be  exercised  as  the  imjjortant  structures  may  be  closely  adherent  to  the 
tumor.  If,  then,  further  efforts  to  separate  the  tumor  be  unwise,  the  sepa- 
rated portion  should  be  cut  away  and  the  remainder  left  in  place.  Often 
under  these  circumstances  the  remaining  portion  becomes  with  increasing 
growth  more  superficial,  when  it  can  be  removed.  The  division  of  and 
turning  aside  of  the  ramus  of  the  jaw  has  been  done  in  some  instances  to 
gain  more  room.  The  limited  space  in  which  the  gland  is  located  leads  to 
early  adhesions  at  its  important  aspects.  Preliminary  ligature  of  the  exter- 
nal carotid  lessens  the  amount  of  the  bleeding  from  the  arteries  directly 
concerned  in  the  operation.  Kespiratory  aspiration  exercises  its  influence 
on  the  veins  involved  in  the  operation. 

The  BesuUs. — This  operation  has  been  done  upward  of  200  times. 
When  performed  for  malignant  growths,  the  disease  has  almost  invariably 
returned  within  six  months.  The  dangers  to  life  from  the  operation  itself 
are  about  12  per  cent;  only  a  few  cases  of  cure  of  malignant  disease  are 
reported. 


76 


CHAPTER   XVII. 


OPERATIONS  ON  THE   URINARY  BLADDER. 

The  cavity  of  the  bladder  may  be  explored  by  catheters,  by  sounds  (Fig- 
1494),  and  by  searchers  (Fig.  1157) ;  inspected  by  the  cystoscope  (page  1159) 
and  through  an  opening  above  the  pubes ;  its  outer  surface- 
is  examined  by  rectal  and  abdominal  joalpation. 

The  catheters  can  be  practically  divided  into  the  soft- 
rubber,  silk,  gum-elastic,  and  metal  varieties.  The  first  two 
varieties  are  extremely  flexible,  and  are  harmless  instru- 
ments in  the  clumsiest  hands  (Fig.  1304,  a).  It  is  sometimes 
necessary  that  a  soft-rubber  catheter  be  provided  with  a. 
guide  in  order  to  properly  direct  it  as  w^ell  as  to  overcome 
any  slight  impediment  in  its  course  (Fig.  1299).  The  gum- 
elastic  and  metal  instruments  especially  modified  for  dis- 
tinct purposes  will  be  considered  later. 

The  Care  of  Catheters  and  Sounds. — Sounds  and  metal 
catheters  should  be  maintained  in  a  j^erfectly  smooth  and 
polished  state,  and  so  protected  as  not  to  be  roughened  or 
dented.  These,  like  other  instruments,  should  be  thorough- 
ly cleansed  and  sterilized  before  using.  If  before  using 
either  be  dipped  into  alcohol  and  the  alcohol  ignited,  suffi- 
cient sterilization  is  made  to  meet  the  purpose.  Metallic 
instruments  can  be  readily  sterilized  by  passing  them  care- 
fully in  the  flame  of  a  Bunsen  burner.  Sterilized  oily  sub- 
stances are  good  lubricants  for  the  metal  instruments,  and 
castor  oil  and  fluid  alboline  are  the  best  examples  of  these- 
substances.  But  soft-rubber  instruments  are  rapidly  dete- 
riorated by  oleaginous  substances.  White  and  Martin  rec- 
ommend the  following  lubricant  for  rubber  instruments — 
in  fact  it  may  be  used  for  all : 

^,   Boroglyceride i  iij  5 

M.  Aquae  destil f  3  ix. 

Rubber  instruments  are  not  only  purified  but  benefited  by 

^^     ..       .,      boiling,  while   textile  instruments,   protected    by   varnish,. 

\^     \si^      soon  blister  and  crack  from  the  effects  of  heat.     Special 

Fig.  1399.  apparatus  for  sterilization  of  all  varieties  of  urethral  instru- 

Keyes's  qathe-    ments  can  be  procured  in  the  supply  stores  of  large  cities. 

ter  guide.     6.    Qj^jy  suitably  sterilized  instruments  should  be  introduced 

Otis  s     eathe-  -^  ■' 

ter  guide.  into  the  urethra  and  bladder,  and  the  same  precautions. 

1108 


OI'KIfATlONS   ON    'I'lIK    IKINAKV    BLADDER. 


1109 


Fig.  1300. — The   introduction  of  catheter,  first  step.      Instrument 
parallel  with  alidomen. 


should  cluiniclcri/.e  their  use  :is  iire  pructiceil  in  general  operative  procedures. 
The  meatus  should  be  wiped  olT  with  aseptic  cotton  saturated  with  a  steril- 
ized fluid  before  a  sound  or  oihvv  iustrutiuuit  is  introduced.    The  urethra  and 

meatus  can  be 
thoroughly  ster- 
ilized by  irriga- 
tion with  a  per- 
manganate solu- 
tion of  1  to  5,000. 
Washing  out  the 
bladder  is  prac- 
ticed by  some 
surgeons,  after 
the  introduc- 
tion into  it  of 
an    instrument. 

77ie  Introduction  of  a  Catheter  or  Sound  into  the  Bladder. — Select  an 
instrument  of  a  suitable  curve  and  size ;  place  the  patient  on  the  back,  with 
the  shoulders  somewhat  raised  and  the  thighs  slightly  flexed  on  the  abdo- 
men, and  rotated  outward  to  relax  the  abdominal  muscles ;  warm  and  smear 
the  instrument  with  a  properly  sterilized  substance;  stand  on  the  left  side 
of  the  patient ;  grasp  the 
penis  with  the  middle 
and  ring  fingers  of  the 
left  hand  and  raise  it 
vertically.  The  catheter 
or  sound  is  then  taken 
lightly  between  the 
thumb,  index,  and  mid- 
dle fingers  of  the  right 
hand,  and  introduced  in- 
to the  meatus  held  open 
by  the  left  index  fin- 
ger and  thumb. 
The  instrument  and 
penis  should  now  be  ' 
carried  close  to  the 
body  in  the  line  of  the 
groin,  or  over  and  par- 
allel with  abdomen  (Fig. 
1300) ;  the  former  is  the 

common  manner.  The  penis  is  then  gently  drawn  over  the  instrument, 
which  at  the  same  time  is  carefully  pushed,  or  allowed  to  enter  by  its  own 
weight,  into  the  canal  (Fig.  1301).  After  about  five  inches  of  the  instru- 
ment have  disappeared,  the  outer  extremity  should  be  carried  toward  the 
median  line  of  the  body  of  the  patient  and  elevated  slowly  to  a  vertical  posi- 
tion, when  its  weight  will  usually  cause  the  advancing  end  to  pass  beneath 


Fig.  1301. — The  introduction  of  catheter,  second  step. 


1110 


OPERATIVE  SURGERY. 


Fig.  1302.- 


-The  introduction  of  catheter, 
third  step. 


the  pubes,  after  which  the  upper  extremity  is  depressed  between  the  thighs, 
causing  the  point  to  enter  the  bladder  (Fig.  i;3()2). 

The  Comments. — In  passing  a  catheter  with  a  stylet,  hold  the  latter  firmly 
in  place,  or  the  end  may  escape  through  the  eye  of  the  catheter  and  lacer- 
ate the  urethra.  Not  infrequently 
the  advancing  end,  as  it  passes  be- 
neath the  arch  of  the  pubes,  will 
hitch  upon  the  triangular  ligament. 
This  can  be  obviated  by  raising  the 
point  of  the  instrument  at  this  situ- 
ation by  the  finger  pressed  firmly 
against  the  median  line  of  the  peri- 
nseum,  accompanied  by  upward 
traction  on  the  instrument  as  the 
point  is  being  advanced  (Fig.  1303) ; 
in  a  word,  causing  the  instrument 
to  hug  the  roof  instead  of  the  floor 
of  the  canal.  The  beginner  is  apt 
to  carry  the  handle  of  the  instru- 
ment between  the  thighs  too  soon,  causing  the  beak  to  be  reversed  in  front 
of  the  pubes.  Under  no  consideration  must  violence  be  employed  in  intro- 
ducing a  catheter,  ars  non  vis  being 
an  almost  traditional  axiom  in  this 
connection.  The  surgeon  should  al- 
ways follow  the  advancing  end  of  the 
instrument  with  the  mind's  eye,  aim- 
ing to  keep  it  in  the  axis  of  the  ure- 
thral curve.  The  first  approach  of 
the  instrument  to  the  perineal  por- 
tion of  the  urethra  not  infrequently 
causes  a  contraction  of  the  muscles 
of  this  region,  which  interposes  an 
effective  temporary  obstacle  to  its 
advancement.  If,  however,  the  pa- 
tient's attention  be  engaged  in  con- 
versation or  otherwise  diverted  from 
the  procedure,  while  at  the  same 
time  the  end  of  the  instrument  is 
pressed  continuously  and  carefully 
against  the  obstacle,  it  will  soon  give 
way  and  enter  the  bladder  without 
further  trouble.  If  the  instrument 
be  a  catheter,  the  flow  of  urine  usu- 
ally announces  its  entrance  into  the 

bladder.  If  the  eye  of  the  catheter  be  obstructed,  or  a  sound  be  used,  the 
exact  situation  of  the  instrument  may  be  determined  by  rotating  it  on  its 
long  axis,  when,  if  the  beak  be  in  the  viscus,  its  extremity  will  describe  the 


W 


Fig.  1303.— The  introduction  of  catheter,  dis- 
engaging end  of  instrument  from  trian- 
gular ligament. 


OTKliATlONS   ON    TIIK    L'I{INAI{V    HLADDHK. 


nil 


Fig.  1304. — Instruments  employed  in  the  treatment  of  retention  of  urine. 

Conical  soft-rubber  catheters,  one  with  stylet,  b.  Conical  frum-elastic  catheters,  one 
with  stylet,  c.  Flexible  single-  and  double-elbowed  catheters,  d.  Olive-pointed 
flexible  "catheters,  e.  Pointed  soft-rubber  catheter.  /.  Holt's  self-retaininp:  cathe- 
ter, g.  JacoVis's  self-retaining  catheter  for  bladder  drainage.  h.  Small  glass 
syringe,  i.  Ordinary  ami  prostatic  silver  catheters,  j.  Tunneled  catheter  and 
whcvlebone  guide,  k.  Tunneled  sound  and  whalebone  guide.  /.  Wiper,  in.  Female 
catheter,  n.  Tenaculum  and  blunt  retractor,  o.  Curved  probe-  and  sharp-pointed 
bistouries,  p.  Scalpels,  q.  Straight  and  curved  tractors  and  cannula\  r.  Long 
needle  and  traction  loops.  Forcipressure.  scissors,  forceps,  wipers,  small  sponges, 
sponge  holders,  abundant  gauze,  sutures,  ligatures. 


1112  OPERATIVE  SURGERY. 

arc  of  a  circle  around  its  shaft  as  a  center ;  if  it  do  not,  then  the  shaft  will 
describe  a  circle  around  its  beak.  If  the  bladder  be  empty  or  contracted, 
the  impingement  of  the  beak  upon  its  walls  may  not  be  recognized,  thus 
deceiving  the  beginner  and  also  causing  the  patient  much  pain.  The  intro- 
duction of  the  index  finger  into  the  rectum  will  aid  in  guiding  the  instru- 


G5=->="^ 


!#:=> 


Fig.  1305. — Filiform  bougies. 


ment  into  the  bladder,  and  determine  the  fact  of  its  entrance  as  well.  Hot 
fomentations  to  the  abdomen,  together  with  an  anodyne  and  perhaps  a  ten- 
grain  dose  of  quinine,  may  be  employed  if  a  urethral  chill  be  feared.  The 
injection  into  the  urethra  of  a  weak  solution  of  carbolic  acid  and  oil  after 
the  withdrawal  of  the  instrument,  and  Just  before  urination,  will  diminish 
the  smarting,  and  is  thought  by  some  surgeons  to  lessen  the  severity  and 
prevent  urethral  chills. 

Retention  of  Urine. — Retention  of  urine  depends  upon  some  obstruction 
to  its  egress  located  at  the  neck  of  the  bladder  or  in  the  course  of  the 
urethra  ;  also  upon  paralysis  of  the  muscular  coats  of  the 
bladder,  or  upon  all  combined.  v 

The  indications  are  met  by  overcoming  the  obstruc- 
tion or  restoring  tone  to  the  bladder.  /v. 

Tlie  Retention  from   Stricture. — If   the  obstruction 

be  due  to  stricture,  and  it  is  permeable,  catheterism  will 

effect  ready  relief.     If  it  be  impossible  to  introduce  an    ^       „.^     ^^     ,    , 
,^     ,  J.  n      •  .     Fig.  1306.— Goulev  s 

ordinary  catheter,  even  of   a  small   size,  recourse  must     whalebone  guides. 

then  be  had  to  filiform  bougies  (Fig.  1305)  or  whalebone 
guides  (Figs.  1306  and  1501).  The  patient  is  placed  in  the  dorsal  position,  and 
sometimes  local  ansesthesia  is  employed.  If  general  anaesthesia  be  necessary, 
it  is  advisable  to  relieve  a  much-distended  bladder  of  some  portion  of  the  fluid 
by  suprapubic  aspiration  (page  1116)  to  avoid  the  danger  of  rupture  during 
the  struggles  of  the  patient.  If  one  be  not  entirely  familiar  with  the  use 
of  the  whalebone  guides  and  the  tunneled  catheter  (Figs.  1307  and  1309), 
neither  local  nor  general  anaesthesia  is  advisable,  as  then  the  patient's  sen- 
sations can  not  be  consulted,  and  great  harm  might  arise  from  their  use. 

The  Introduction  of 
Whalebone  Guides. — 
After  cleansing  the 
meatus  and  glans  (page 
1109),  the  urethra  is 
Fig.  1307.— Gouley's  tunneled  catheter  and  whalebone  guide,    forcibly      filled       with 

sterilized  oil  by  means 
of  a  syringe  (Fig.  1304,  //),  and  the  end  of  the  penis  grasped  to  retain  the  fluid, 
leaving  sufficient  room  at  the  meatus  for  the  introduction  of  the  whalebone 
guide.  A  guide  is  carefully  introduced,  and  if  its  point  becomes  engaged  in 
a  lacuna  (Fig.  1308,  c),  it  is  withdrawn  a  little  and  again  carried  onward  with 


OrKKATIOXS   OX   TIIK    L'KI.NAUV    I'.I.ADDHK. 


1113 


A  rotary  motion.  If  it  enter  a  false  passage,  or  is  arrested  by  a  stricture, 
it  is  allowed  to  remain  there,  while  another  guide  is  passed  by  its  side,  and 

so  on  until  four  or  six,  or  even  more,  are  con- 
tained in  the  canal  (c),  some  of  which  have  the 
spiral  and  others  the  straight  or  elbowed  end 
foremost.  Each  one  is  then  taken  separately 
and  pressed  onward,  with  or  without  the  rota- 
tory motion,  always  remembering  to  use  no 
force,  else  the  small  points  may  pierce  the  mu- 
cous membrane  of  the  urethra,  or  enter  and  per- 
forate Cowper's  ducts.  As  soon  as  all  the  side 
Fig.  i;{08.— The  introdiiction  of  openings  are  closed  by 

whalebone  j^uules.     (i.  Guide      ,  '         ...  «      , 

bent   upward,      b.  Guide   in    <^"e    extremities    of    the 

lacuna,     c.  Numerous  guides    guides,  one  guide  will  be 

in  urethra,  one  passiner  stric-    j.        j     ,      v  ,        ■, 

i^j.Q  ^        "  found   to  have  entered 

the  stricture  (c),  and, 
with  a  little  coaxing,  will  pass  into  the  bladder,  which 
is  known  by  the  painless  ease  with  which  it  can  be 
moved  in  and  out.  The  others  are  then  withdrawn, 
and  the  end  of  the  one  remaining  is  passed  through 
the  eye  of  a  tunneled  sound  (Figs.  1304,  k,  and  1309), 
•or,  what  is  better,  the  tunneled  catheter  (Figs.  1307 
and  1304,  /).  The  guide  serves  to  direct  the  passage 
of  the  instrument  into  the  bladder,  which  should  be 
•done  cautiously,  as  the  guide  may  be  cut  by  the  eye 
■of  the  instrument,  causing  it  to  double  and  direct 
the  end  of  the  catheter  astray.  When  the  instru- 
ment is  in  the  bladder  urine  flows  freely,  and  the 
beak  can  be  turned  from  side  to  side  around  the 
long  axis  of  the  stem.  After  the  requisite  amount 
•of  urine  is  withdrawn,  a  tunneled  sound  of  larger 
size  may  be  passed  in  a  similar  manner  as  the  tun- 
neled catheter,  after  which  the  guide  can  be  taken 
■out  and  an  ordinary  steel  sound  of  proper  size  care- 
fully introduced  to  insure  a  channel  of  sufficient 
•capacity  to  admit  the  ready  entrance  of  an  instru- 
ment thereafter. 

The  Comments. — A  whalebone  guide  may  bend, 
turn  upon  itself  (Fig.  1308,  a),  and  become  arrested. 
It  is  important  to  know  that  the  bladder  should  not 
be  entirely  emptied  of  its  contents,  but  that  only  a 
sufficient  amount  of  urine  should  be  drawn  to  afford 
•complete  relief  from  all  pain  and  tension.  If  it  be 
■completely  emptied,  its  walls  will  collapse  from  want 
of  support,  causing  congestion  of  the  lining,  and  in 

:all  probability  the^catheter  will  be  required  at  one  or  ^^<^-  I309.-Gouley's  tun- 
'  • .  '  neled  sound  and  whale- 

jnore  succeeding  attempts  at  urination.      But  if  a        bone  guide. 


1114 


OPERATIVE  SURGERY. 


third  or  a  half  of  the  contents  be  withdrawn,  the  bhidder  is  likely  to  expel 
its  contents  properly  when  the  occasion  next  requires.  A  failure  to  enter 
the  bladder  finally  calls  for  perineal  section  (j)age  12-49). 

Retention  from  Enlarged  i'rostate. — In  retention  from  this  cause  prompt 
relief  should  not  be  limited  by  palliative  procrastination.  In  the  major- 
ity of  instances  the  invag-inated  (Fig.  1500) 
single-  or  donble-elbowed  flexible  catheter  (Fig. 
1304:,  c)  can  be  quite  readily  passed;  failing  with 
tliis,  the  introduction  of  the  soft-rubber  instru- 
ment, with  the  ordinary  stylet  (Fig.  1304,  a)  to 
maintain  the  needed  form  and  rigidity,  can  be 
tried  at  different  curves.  The  silver  prostate 
catheters  (Fig.  1304,  i)  and  the  malleable  one  of 
block  tin  can  be  employed,  but  always  with  in- 
finite care.  The  form  of  the  latter  can  be 
easily  changed  by  bending  to  meet  the  demands 
of  a  devions  entrance  to  the  bladder,  and  has 
repeatedly  been  nsed  by  the  writer  with  grati- 
fying resnlts.  However,  its  liability  to  bend 
and  break  when  used  with  unwise  manipulative 
force  should  be  recognized  and  heeded.  In 
rare  instances  the  whalebone  guide  and  long  curved  tunneled  catheter  may 
solve  the  difficulty,  but  the  danger  from  their  immoderate  use  is  not  to  be 


Fig.  1310.— The  temporary  fas- 
tening in  place  of  a  flexible 
catheter. 


Fig.  1311.— The  fastening  of  a  catheter  in  place,  Dittel's  method,    a.  Adhesive  plaster  col- 
lar,    h.  Retention  plaster  holding  pin.    c.  Strip  binding  others  in  position. 

underestimated.    The  too  pointed  extremity  and  improper  curve  of  the  latter 
unfit  it  for  common  use.     The  length  of  time  employed  in  these  manipula- 


orKKATlUNS   UN    THE    IJUNAKV    BLADDER. 


1115 


tions  should  be  liniitfd  to  ten  or  fifteen  minutes,  and  the  vigor  of  the  effort 
sliDuid  be  of  a  eonservative  character.  At  the  best,  some  bleeding  will  fol- 
low in  many  instances,  regardless  of  the  instrument  employed.  If  entrance 
to  the  bladder  be  gained  only  after  considerable  dithculty,  the  catheter  should 
be  fastened  in  place  by  one  of  several  methods  (Fig.  1310)  and  permitted  to 
remain  for  a  time,  and,  if  withdrawn,  be  quickly  followed  by  a  flexible  one, 
which  is  permitted  to  remain  at  least  for  forty-eight  hours  undisturbed. 
OontiTiuous  catheterism  can  be  practiced  for  two  or  three  weeks  if  frequent 
cleansing  of  the  urethra  and  the  catheter  be  employed  (Fig.  1311).  The 
tape  holding  the  instrument  in  place  may  be  pinned  to  a  bandage  passed 
around  the  body.  If  the  surgeon  fail  to  enter  the  bladder,  he  should  then 
resort  to  suprapubic  aspiration,  or  puncture,  or  to  perineal  section. 

Puncturing  of  the  Bladder. — Puncturing  the  bladder  is  done  to  relieve 
the  organ  from  overtlistention.     The  puncture  can  be  made  either  above  or 
below  the  pubes,  and  through  the  rectum.     It  may  be  performed  by  direct 
incision  with  the  ordinary  curved  trocar, 
and  by  aspiration,  the   latter   being  the 
safer    and    often   the    more    satisfactory 
way. 

The  Ayiatomical  Points. — The  ana- 
tomical points  are  considered  under  Su- 
prapubic Lithotomy  (page  1197). 

Suprapubic  Puncture.  — "  Suprapubic 
puncture  is  the  operation  of  choice,"  says 
Alexander,  "  in  cases  of  retention  due  to 
enlarged  prostate  in  which  catheterization 
is  impossible.  It  may  also  be  advantage- 
ously employed  in  cases  of  retention  due 
to  old  induration  from  stricture,  especially 
when  the  latter  is  of  traumatic  origin  and 
associated  with  false  passages,  and  in 
which  catheterization  is  impossible.  In 
such  cases  the  choice  must  be  made  be- 
tween perineal  section   without   a   guide 

and  suprapubic  puncture  combined  with  retrograde  catheterization,  to  be  at 
once  followed  by  perineal  section." 

'The  Operatio?i  by  Direct  Incision  {Suprapubic  Cystotomy). — As  Alexan- 
der truly  says,  "  The  operation  may  be  performed  under  local  cocain  ana?sthe- 
sia  in  cases  where  a  general  anjesthetic  is  inadvisable.  The  pubis  is  shaved 
and  the  skin  scrubbed  and  disinfected.  An  incision  about  an  inch  and  a  half 
long  is  made  in  the  middle  line,  beginning  at  the  symphysis  pubis  (Fig. 
1312).  The  skin  and  fascife  are  divided  down  to  the  linea  alba.  The  rectus 
muscles  are  carefully  separated  and  held  apart  by  small  retractors.  If  the 
bladder  be  distended,  the  perivesical  fascia  and  fat  will  appear  at  the  bottom 
of  the  wound.  They  are  divided  and  drawn  to  the  upper  part  of  the  wound, 
and  a  round,  sharp  bistoury  is  then  plunged  into  the  bladder  at  the  lowest 
part  of  the  anterior  wall,  and  an  incision  large  enough  to  admit  a  25  F. 


Fig.  1312. — The  operation  by  supra- 
pubic incision.  The  peritoneal  re- 
flexion seen  at  the  upper  angle  of 
the  incision. 


1116 


OPERATIVE   SURGERY. 


catheter  is  made  as  the  knife  is  withdrawn.    The  catheter  is  then  introduced 
and  fixed  in  place,  and  the  Avouud  closed  up  to  the  catheter." 

The  Operation  hy  Aspiration. — The  contents  of  the  bladder  can  be  re- 
moved by  aspiration  by  introducing  the  aspirating  needle  into  the  organ 
above  the  pubes  at  the  point  indicated  for  the  passage  of  a  trocar  (Fig. 
1313).  This,  however,  is  a  temporary  measure  only.  The  same  can  be 
said  of  tapping  per  rectum.  These  expedients  are  important,  as  they  enable 
the  surgeon  to  gain  time  for  the  performance  of  external  perineal  urethrot- 
omy or  otherwise  to  afford  relief.  If  aspiration  be  practiced  with  aseptic 
precautions,  it  may  be  performed  two  or  three  times  daily  for  quite  as  many 
weeks  in  cases  not  afflicted  with  pronounced  cystitis  with  no  unfavorable 
outcome.  The  suction  force  should  be  continued  during  the  withdrawal  of 
the  needle  to  prevent  urine  from  infecting  the  line  of  puncture  at  that  time. 
The  Operation  with  a  Trocar. — After  thorough  preparation,  as  in  the 
preceding  instances,  place  the  patient  on  the  back ;  outline  the  distended 
^  bladder    by    percus- 

sion ;  explore  the  tu- 
mor with  a  hypoder- 
mic needle  if  a  doubt 
exists  as  to  its  nature 
(Fig.  1313).  Select 
a  small  straight  or 
curved  trocar,  the 
latter  being  the  bet- 
ter ;  make  the  skin 
tense  at  a  point  about 
an  inch  above  the 
pubis,  and  push  the 
trocar  through  the 
median  line  with  its 
convexity  upward. 
An  initiatory  incision 
through  the  skin  is 
often  made  with  a 
sharp  knife,  which 
permits  the  easier  en- 
trance of  the  trocar.  A  preliminary  injection  of  cocain  may  relieve  the 
patient  of  the  pain  caused  by  the  introduction  of  the  trocar. 

Puncture  under  the  Pubes. — If  the  bladder  be  small  and  shrunken  behind 
the  pubes,  or  the  prostate  be  too  large  to  admit  of  the  rectal  puncture,  the 
penis  can  be  pulled  downward,  and  a  small,  curved  trocar,  with  the  con- 
cavity upward,  passed  just  beneath  the  arch  of  the  pubis  into  the  viscus. 

Puncture  through  the  Rectum. — In  puncturing  by  this  route  it  is  im- 
portant to  empty  the  lower  bowel  and  thoroughly  cleanse  the  rectum  ;  place 
the  patient  in  the  lithotomy  position,  and  introduce  the  left  index  finger 
into  the  rectum ;  locate  the  vesiculae  seminales  and  base  of  the  prostate ; 
place  the  end  of  the  finger  between  the  former,  allowing  it  to  rest  upon  the 


Fig.  1313. — Suprapubic  puncture  of  the  bladder  with  trocar,  tlie 
fingers  indicating  seat  of  puncture.  Eye  of  cannula  is  indi- 
cated. 


OPERATIONS   OX    TIIK    UKINAia'    I'.I.A  DDEll.  m^ 

base  of  tlio  prostato  ;  carry  along  tlie  j)al mar  surface  of  the  finger  a  curved 
trocar,  and  ])ush  into  the  bhidder  just  above  the  base  of  tlie  ])rostate ;  willi- 
draw  the  trocar,  leaving  the  cannula  in  place,  tying  it  in  position,  or  substi- 
tuting a  soft  catheter  passed  through  the  cannula  before  removal. 

'I'lie  almost  universal  practice  of  eni])loying  aspiration,  and  the  sujjericjritv 
of  this  method  over  that  of  the  trocar,  has  quite  consigned  the  latter,  along 
with  rectal  puncture,  to  an  honorable  remembrance  only. 

Tlte  Renutrks. — Puncture  of  the  bladder  is  performed  to  relieve  the  organ 
from  overdistention  when  for  any  reason  external  j)erineal  urethrotomy  is 
impossible  or  not  immediately  desirable.  Puncture  above  the  pubes  is  de- 
void of  operative  danger  unless  a  mistake  is  made  in  the  diagnosis.  The 
escape  of  urine  should  be  regulated  the  same  as  in  catbeterism,  when  prac- 
ticable, and  for  a  similar  (page  1113)  reason.  Sometimes  the  relief  of  over- 
distention will  permit  later  the  introduction  of  a  catheter  through  the  proper 
channel. 

Rupture  of  the  Bladder. — Kupture  of  the  bladder  may  be  either  extra- 
peritoneal (15  per  cent)  or  intraperitoneal  (85  per  cent).  Pupture  occurs 
most  frequently  at  the  posterior  surface,  the  urine  escajjing  into  the  peri- 
toneal cavity  causing  peritonitis.  When  the  rupture  occurs  anteriorly  the 
urine  infiltrates  the  tissues  of  the  walls  of  the  abdomen  and  perineum,  causing 
extensive  cellulitis  and  diffuse  suppuration.  The  history  of  injury,  the  pres- 
ence of  bloody  urine,  and  the  failure  to  recover  by  catheterism  a  definite 
amount  of  injected  sterile  fluid  are  among  the  decisive  symptoms  of  rupture. 

//■  tlie  r^ipture  be  intraperitoneal,  the  abdomen  should  be  opened  in  the 
median  line  upward  from  the  pubes  six  or  eight  inches,  the  intestines  held 
aside  with  sterile  pads,  and  the  vesical  opening  sought  for.  When  found, 
it  can  be  satisfactorily  closed  by  either  Cushing's  (Fig.  785),  Halsted's  (Fig. 
79'-2),  or  the  Czerny-Lembert  (Fig.  788)  suture  in  the  same  manner  as  for 
intestinal  wounds.  Purse-string  sutures  are  employed  (Fig.  1412).  The 
blood  clots  and  urine  are  then  carefully  removed  from  the  peritoneal  cavity 
by  sponging  and  irrigation  with  hot  normal  saline  solution.  A  moderate 
distention  of  the  bladder  with  aseptic  fluid  will  test  the  integrity  of  the 
sewing.  If  the  opening  be  not  disclosed  by  inspection  through  the  abdomi- 
nal incision,  the  leakage  following  the  injection  into  the  bladder  of  a  mod- 
erate amount  of  saline  or  of  Thiersch's  fluid  will  reveal  the  site  of  rupture. 
Careful  cleansing  and  drainage,  etc.,  attended  with  continuous  catheterism 
for  several  days,  and  confinement  in  bed,  are  demanded.  If  the  wound  be 
large,  irregular,  and  lacerated,  the  line  of  sewing  is  less  secure,  and  the 
demand  for  drainage  is  the  more  positive  and  prolonged. 

If  the  Rupture  he  Extraperitoneal. — The  presence  of  an  extraperitoneal 
rupture  may  be  told  by  the  area  of  abdominal  extravasation  before  operation, 
or  be  determined  only  after  the  performance  of  laparotomy.  In  either  case 
the  seat  of  rupture  is  established  through  a  suprapubic  opening  in  the  blad- 
der, and  further  exposed  by  properly  directed  external  incisions.  The  open- 
ing is  closed  as  before,  and  the  wound  thoroughly  drained  with  gauze.  The 
sewing  in  cases  of  extravasation  from  rupture  is  comparatively  insecure  on 
account  of  the  absence  of  the  serosa  and  the  presence  of  established  infec- 


1118  operatrt:  surgery. 

tion.  The  abdominal  wound  is  closed  up  to  the  point  of  leaving  ample  room 
for  the  escape  from  the  prevesical  space  of  drainage  agents  just  above  the 
pubis. 

The  Rernarhs. — The  introduction  into  the  rectum  of  the  finger,  followed 
by  pressure  upward  against  the  base  of  the  bladder  during  injection  of  the 
test  fluid,  will  enable  the  surgeon  to  estimate  correctly  the  degree  of  vesical 
distention  attending  the  act.  The  rupture  is  usually  located  posteriorly 
midway  between  the  summit  and  base  of  the  organ.  If  the  rupture  be  low 
down,  the  use  of  the  inflated  rectal  bag  will  bring  the  parts  under  better 
command.  Division  of  the  parietal  peritonseum  at  either  side  of  the  blad- 
der (MacCormac)  may  be  needed  to  effect  the  proper  exposure.  MacCormac 
advises  catheterism  at  suitable  intervals  with  a  soft-rubber  instrument  in  lieu 
of  the  continuous  plan  of  treatment.  The  injection  of  air  or  hydrogen  gas 
into  the  bladder  for  diagnostic  purposes  is  practiced  much  less  than  that  of 
water.  In  other  respects  there  is  comparatively  little  to  express  in  favor  of 
their  use.  If  the  rupture  be  small  and  inflammation  around  it  have  already 
taken  place,  the  fluid  may  not  escai:)e  into  the  peritoneal  cavity  at  first, 
requiring  repeated  and  often  large  injections  for  the  purpose.  Free  manipu- 
lation of  the  bladder  through  the  rectum  with  the  finger,  or  pressure  upon 
it  by  a  distended  Barnes  dilator,  may  develop  the  presence  of  rupture.  The 
writer  once  met  with  a  case  with  limited  extravasation  so  incased  by  adhe- 
sions behind  the  bladder  that  when  distended  it  resembled  the  outlines  of 
an  uninjured  organ.  The  opening  was  small,  and  no  doubt  the  end  of  the 
catheter  conveying  the  fluid  passed  into  it.  If  one  be  satisfied  that  no  infec- 
tion remains  in  the  peritoneal  cavity,  the  abdominal  wound  may  be  closed 
at  once  ;  if  otherwise,  suitable  drainage  should  be  provided.  If  the  rupture 
be  near  the  base,  the  need  of  the  frequent  and  possibly  continual  use  of  the 
catheter  for  a  few  days  is  emphasized.  In  prevesical  rupture  free  drainage 
of  the  bladder  and  of  the  infiltrated  tissues  should  be  had.  Continuous 
drainage  of  the  bladder  by  a  catheter  should  be  superseded  by  suprapubic 
siphon  drainage  (page  1125  et  seq.),  or  drainage  by  a  perineal  cystotomy  in 
case  of  doubtful  eflBciency  or  the  occurrence  of  complicating  objections. 

The  Results. — If  the  operation  be  done  promptly,  and  the  urine  be 
sterile,  the  prognosis  is  good.  If  the  case  be  delayed,  or  the  urine  be  infect- 
ive, the  prognosis  is  correspondingly  bad. 

The  death  rate  from  intraperitoneal  rupture  with  operation  is  about  40 
per  cent,  in  the  extraperitoneal  about  38  per  cent.  During  the  last  fifteen 
years  the  death  rate  has  been  reduced  fully  50  per  cent. 

Cystotomy. — Cystotomy  consists  in  opening  the  bladder  through  the 
perinaeum  usually,  or  above  the  pubes.  These  operations  are  called  respec- 
tively perineal  cystotomy  and  suprapubic  cystotomy.  It  is  practiced  not 
infrequently  for  the  relief  of  obstruction  due  to  enlarged  prostate,  for  invet- 
erate cystitis,  and  to  afford  digital  examination  and  ocular  inspection  of  the 
cavity  of  the  bladder,  and  for  the  removal  of  morbid  formations. 

Perineal  Cystotomy. — Perineal  cystotomy  consists  in  opening  into  the 
bladder  through  the  median  line  of  the  perinaeum,  as  in  the  median  opera- 
tion for  stone  (page  1192). 


Ul'KUATlUNS    ON    THE    L'UINAKV    BLADDHIi.  Jill) 

The  anatomical point)^  arc  noted  iimler  Litliotoiny  (]);i<,af  118'^). 

The  Operation. — IMace  the  ])atic'nt  on  the  back,  evacuate  the  rectum,  in- 
troduce a  grooved  staiT  into  the  bhulder,  and  witli  a  sharp  knife  make  an 
incision  in  the  median  line  about  two  inclies  in  length,  terminating  about 
half  an  inch  in  front  of  the  anus;  by  repeated  and  successively  shortened 
ajiplioations  of  the  knife — carefully  avoiding  the  ])ulb — the  statf  is  reached, 
and  the  membranous  nrethra  oj)ened  backward  to  the  apex  of  the  prostate. 
Introduce  a  small  probe  into  the  bladder  by  way  of  the  groove  in  the  staff, 
withdraw  the  staif  cautiously,  carefully  introduce  the  index  finger  into  the 
bladder  along  the  probe  as  a  guide,  and  distend  the  neck  of  the  bladder 
sufficiently  to  cause  the  urine  to  escape  as  fast  as  it  flows  into  the  bladder. 
The  prostatic  structure  must  be  well  dilated,  else  it  will  soon  return  to  its 
normal  condition  and  require  a  repetition  of  the  dilating  process.  The  pros- 
tate may  be  incised  on  either  one  or  both  sides,  as  in  lateral  and  bilateral 
lithotomy,  to  maintain  the  patency  of  the  opening  for  any  length  of  time. 
Cystotomy  is  now  quite  frequently  performed  as  an  ultimate  expedient  in 
obstinate  cystitis  in  both  sexes.  In  the  female  the  incision  is  made  into  the 
bladder  through  the  vagina. 

Suprapubic  C'l/stotonii/. — The  bladder  is  opened  above  the  pubis  by  a 
transverse  (Fig.  903)  or  vertical  incision  (usually  the  latter)  for  various  pur- 
poses, notably  for  removal  of  stone  and  jirostatectomy  (page  1131). 

The  Results. — The  operation  of  cystotomy  alone  implies  but  little  dan- 
ger to  the  patient.  However,  when  done  in  the  presence  of  disease  of  the 
bladder  or  kidneys,  the  final  outlook  is  much  less  promising,  and  can  be  well 
judged  by  the  results  in  operation  for  these  conditions  respectively. 

Cystotomy  for  Tumors. — Tumors  can  be  removed  from  the  bladder  by 
the  perineal  or  the  suprapubic  route.  The  jt»^ri»e«?  row^e  is  the  better  one 
when  the  growth  is  near  to  the  vesical  orifice,  especially  if  the  perina?um  be 
not  deep  and  complicated  by  enlarged  prostate.  Even  in  such  cases  as 
these  the  advantage  gained  by  dependent  drainage  can  not  be  underesti- 
mated, since  it  lessens  the  death  rate,  promotes  the  comfort,  and  contributes 
to  the  recovery  of  the  patient.  After  cystotomy  is  iierformed  and  the  neck 
of  the  bladder  is  dilated,  forceps  with  serrated  blades  and  distinctive  curves 
(Fig.  1314,  /,  /,  k,  I)  are  introduced  into  the  bladder,  opened,  the  tumor  seized 
and  twisted  away — not  pulled,  as  forcible  traction  is  highly  objectionable. 
Eepeated  applications  of  the  forceps,  directed  by  the  finger  in  the  bladder,  are 
made  until  the  tumor  is  finally  removed.  Unusual  bleeding  is  controlled  by 
hot-water  irrigation,  direct  pressure,  etc.  Suitable  drainage  of  the  bladder 
(Fig.  ir23)  should  follow  the  operation  for  some  days,  after  which  the  urine 
is  permitted  to  resume  the  natural  channel.  Gouley,  Cliismore,  and  others 
have  removed  polypoid  growths  through  the  urethra  by  means  of  a  lithotrite. 

The  Commeiits. — Suprapubic  pressure  to  secure  control  of  the  tumor  may 
cause  the  forceps  to  seize  the  bladder  walls  with  obvious  outcome.  Polypoid 
growths  of  all  kinds  can  thus  promptly  be  removed,  but  sessile  ones  of  exten- 
sive growth  are  not  amenable  to  this  treatment. 

The  suprapubic  route  for  the  removal  of  vesical  tumors  affords  the  oppor- 
tunity of   good  observation,  intelligent  manipulation,  and  scientific  tech- 


1120 


OPERATIVE  SURGERY. 


Fig.  1314, — Instruments  employed  in  cystotomy  and  treatment  of  tumors  of  the  bladder. 

a.  Scalpels,  b.  Bistouries,  c.  Forcipressure.  d.  Tcale's  f?orget  and  Brown's  grooved 
catheter  director  for  primary  incision,  e.  Long  forceps.  /.  Grooved  staffs,  g. 
Double-current  catheter,  h.  Long  silver  probe.  i.J,^'.  Thompson's  tumor  forceps. 
I.  Wyeth's  forceps,  m,  n.  Long,  straight,  blunt-pointed,  and  curved  blunt-  and  sharp- 
pointed  scissors.  0.  Safety  pin  and  perineal  drainage  tube.  p.  Assorted  needles. 
A  female  silver  catheter,  elbowed  and  straight  rubber  catheters,  scoops,  rongeur, 
blunt  and  hooked  retractors,  sponge  holders,  tenaculum,  wipers,  ligatures,  traction 
loops,  and  tampons  should  be  at  hand. 


OPERATIONS   ON   THE    I'KINAKV    IJLADDKIt.  11:>1 

niqiie.  The  aiuitotuicjil  points  are  stated  under  Siiprupiil^ic  Litliotoniy 
(page  HOT). 

The  Operation. — After  thorough  cleansing  of  the  abdominal  wall,  jieri- 
nivum,  mucous  and  cutaneous  surfaces  of  the  genitals,  and  of  the  bladder 
and  rectum,  place  the  patient  on  the  back  with  the  hips  and  shoulders  raised 
to  relax  the  abdominal  wall ;  introduce  the  rectal  bag  (Figs.  1407,  1408,  and 
140l»)  above  the  s])hincters,  and  distend  it  witii  six  or  eight  ounces  of  fluid  ; 
inject  into  the  bladder  eight  or  ten  ounces  in  the  adult,  and  in  the  child 
about  half  of  this  amount;  make  an  incision  from  the  pubis  upward  in  the 
mediaji  line  three  or  four  inches  in  length  ;  separate  the  tissues  in  the  median 
line,  going  through  the  fascia  that  bounds  the  prevesical  space  in  front, 
exposing  the  prevesical  fat ;  pass  the  finger  behind  the  pubis,  hook  up  and 
draw  upward  the  prevesical  fat  along  with  the  peritonaeum,  thus  exposing 
the  bladder;  draw  apart  the  borders  of  the  wound  with  retractors  or  traction 
sutures;  flush  the  field  of  operation  with  a  five-per-cent  solution  of  carbolic 
acid,  or  smear  it  with  iodoformized  vaseline  to  prevent  infection  ;  introduce 
at  each  side  of  the  median  line  of  the  bladder,  through  the  muscular  coat  in 
front,  a  traction  suture ;  thrust  through  the  bladder  in  the  median  line,  half 
an  inch  below  the  upper  border  of  the  pubis,  a  bistoury,  and  cut  upward 
sufficiently  to  admit  the  index  finger ;  introduce  traction  sutures  through 
each  border  of  the  wound  of  the  bladder,  and  draw  the  bladder  o^jen  as  the 
incision  is  extended  upward,  duplicating  the  sutures  if  need  be,  or  use  retrac- 
tors instead ;  place  the  patient  in  Trendelenburg's  position  (Fig.  55)  and 
remove  the  rectal  bag ;  cleanse  the  bladder  by  irrigation  and  sponges,  and 
proceed  to  inspect  the  cavity  with  the  electric  light ;  incise  the  bladder 
transversely  if  additional  room  be  needed.  After  exposure  the  growth  is 
removed  by  forceps  (Fig.  1314),  cutting,  cautery  excision,  etc.,  as  seems  to 
best  suit  the  demands  of  the  case. 

The  Remarks. — Tearing  of  the  tissues  should  be  carefully  avoided.  The 
muscular  fibers  should  be  separated  and  fascia  divided,  not  torn.  Bleeding 
points  are  promptly  secured  throughout  the  operation,  and  anticipated  by 
clamping  before  division,  when  feasible.  It  is  wiser  to  carefully  divide  the 
prevesical  fascia  after  drawing  up  the  peritoneal  fold  than  to  tear  it  asunder, 
as  then  infiltration  and  sloughing  are  encouraged.  In  lieu  of  the  traction 
suture  a  tenaculum  can  be  inserted  transversely  into  the  wall  of  the  bladder 
in  the  median  line  just  below^  the  peritoneal  fold  (Figs.  1312  and  1408,  a), 
or  at  the  seat  of  the  upper  limit  of  the  proposed  incision,  which  when  drawn 
upward  supports  the  wall  of  the  bladder  and  protects  the  peritonaeum  from 
injury  at  the  same  time.  The  incision  into  the  bladder  should  be  made  away 
from  avoidable  vessels,  and  the  mucous  membrane  quickly  divided,  otherwise 
it  may  be  pushed  off  the  bladder  wall  and  remain  uncut.  The  finger  is  not 
introduced  until  the  borders  of  the  bladder  wound  are  under  the  control  of 
silk  loops  or  of  forceps,  unless  it  be  done  to  hook  the  bladder  forward  and 
hold  it  while  the  other  restraining  influences  are  being  applied.  The  bor- 
ders of  the  wound  should  be  carefully  treated  in  every  instance.  It  may  be 
advisable  in  rare  instances  in  disease  of  the  bladder  to  sew  the  lips  of  the 
visceral  wound  to  those  of  the  abdominal  incision. 


1122  OPERATIVE  SURGERY. 

Treiidelenhurg  advises  that  a  slightly  convex  transverse  incision  four 
inches  long  be  made  above  the  pubis  (Fig.  963)  with  the  convexity  down- 
ward, in  cases  where  the  bladder  is  small  and  distensible.  The  prevesical 
space  and  the  bladder  are  opened  through  this  incision  without  risk  of  dam- 
aging the  integrity  of  the  peritonaeum. 

Langenhecl-  proposed  a  subpubic  route  through  an  inverted  /^-shaped 
incision  (Fig.  903),  the  arms  of  which  correspond  to  the  course  of  the  rami 
of  the  pubis. 

Helferich  proposed  a  subperiosteal  resection  of  the  pubis  through  a  trans- 
verse incision  made  along  its  upper  border,  to  render  the  bladder  more 
accessible.     Symphysiotomy  has  been  proposed  for  the  same  purpose. 

In-filtrating  tumors  of  the  wall  of  the  bladder  are  readily  treated,  unless 
thev  implicate  the  base  of  the  organ  and  its  important  associations.  If  the 
tumur  involve  the  muscular  coat  only,  the  peritoneum  corresponding  to  the 
growth  is  dissected  off  and  away  from  the  tumor,  the  tumor  removed,  and 
the  muscular  wound  closed  with  sutures,  without  involvement  of  the  peri- 
toneal cavity.  If  the  peritoneum  be  involved,  then  the  entire  thickness 
of  the  wall  must  be  removed,  which  is  done  best  by  the  use  of  a  clamp  and 
through  and  through  sewing  with  catgut,  if  the  physical  aspects  of  the 
tumor  will  permit  of  such  a  course.  The  implication  of  the  ureteral  region 
of  the  bladder  has  a  much  more  serious  aspect,  not  only  on  account  of  the 
ureters  themselves,  and  the  necessity  of  disposing  of  their  discharges,  but 
also  of  the  greater  difficulty  of  repair,  and  the  contiguity  of  important  struc- 
tures. However,  the  base  of  the  bladder,  and,  in  fact,  the  entire  organ  has 
been  removed  successfully  (page  1150).  So  far  as  the  final  disposition  of  the 
ureters  is  concerned,  Clado,  according  to  White  and  Martin,  adopts  the  fol- 
lowing conclusions :  "  Leaving  the  ureter  open  in  the  wound  after  extirpa- 
tion of  a  neoplasm  is  extremely  dangerous.  Implantation  into  the  rectum  is 
almost  invariably  fatal.  Implantation  into  the  colon  (page  862  et  seq.)  is 
more  successful.  Implantation  into  the  parietal  wound  (page  800)  is  some- 
times a  matter  of  necessity.  Implantation  into  the  vesical  cavity  (page  859) 
and  anastomosis  with  the  ureter  of  the  opposite  side  (page  866)  are  the  two 
operations  which  give  the  greatest  promise  of  a  definite  recovery." 

Albarran  summarizes  the  general  treatment  of  malignant  tumors  of  the 
bladder  as  follows :  "  The  patient  should  be  placed  in  the  Trendelenburg 
position  and  the  neoplasm  subjected  to  an  examination.  If  the  tumor  is 
sessile,  if  no  enlarged  lymph  nodes  are  found,  and  if  the  patient  is  in  good 
condition,  resection  of  the  bladder  wall  is  indicated.  This  resection  is  easily 
performed  if  the  tumor  is  placed  above  the  opening  of  the  ureters,  since  it 
is  then  unusually  accessible,  enough  room  being  secured  by  incision  through 
the  attachments  of  the  recti  muscles.  When  the  tumor  is  placed  posteriorly 
in  a  bladder  which  is  naturally  deep  seated,  or  above  the  ureteral  orifice,  or 
behind  the  anterior  wall  of  the  bladder  marked  by  the  pubic  symphysis, 
partial  resection  of  the  symphysis  or  symphysiotomy  may  be  required. 
Resection  of  the  tumor  is  easiest  when  it  is  situated  upon  the  upper  portion 
of  the  bladder  where  the  peritongeum  can  be  readily  stripped  back.  After 
this  stripping,  the  tumor,  with  a  portion  of  the  healthy  bladder  wall,  is  cut 


Ol'KIJATIONS   ON    THK    URINAltV    BLADDKR.  1123 

away  with  scissors  and  the  wound  is  sutured.  If  tlie  tumor  is  phiced  above 
the  ureters  posteriorly  it  may  be  circumscribed  by  an  inci-sion  througli  the 
mucous  membrane  and  resected  from  within  outward,  no  efTort  being  made 
to  strip  the  peritoiuuum  tirst.  If  the  tumor  is  placed  about  the  orilice  of  the 
ureter,  the  latter  should  be  catheterized,  should  then  be  exposed  by  cutting 
through  the  lateral  wall  of  the  bladder,  and  should  be  freed  aiul  implanted 
into  the  healthy  wall  of  the  viscus.  If  this  operation  is  impossible,  the 
wound  nuule  through  tlie  bladder  wall  for  the  purpose  of  exposing  the 
ureter  sliould  be  closed,  and  the  urine  escaping  through  the  ureteral  catheter 
should  be  examined  carefully.  If  the  urine  is  clear,  showing  that  tiie  kid- 
ney is  not  infected,  the  catheter  should  be  withdrawn  and  the  ureter  should 
be  ligated,  divided  below  the  ligature,  and  suitably  implanted  (page  859  et 
seq.).  If  the  urine  escaping  through  the  catheter  is  turbid,  showing  admix- 
ture of  pus,  the  ureter  should  be  divided  and  fixed  to  the  abdominal  wound. 
Whatever  procedure  is  employed  for  the  purpose  of  giving  more  room,  the 
bladder  should  be  closed  completely,  a  permanent  catheter  should  be  intro- 
duced, and  the  prevesical  space  should  be  packed  with  iodoform  gauze. 
Total  resection  of  the  bladder  is  indicated  only  in  the  case  of  multiple 
epitheliomata  which  have  not  yet  extended  beyond  the  muscular  wall." 

After  removal  of  the  tumor,  arrest  the  hremorrhage  and  drain  the  blad- 
der through  the  suprapubic  opening,  through  the  urethra,  or  by  perineal 
urethrotomy.  Chromicized  catgut  sutures  carried  down  to  but  not  through 
the  mucous  membrane,  and  placed  about  a  quarter  of  an  inch  apart,  should 
be  employed,  so  as  to  hug  closely  the  drainage  tubes  (page  112(!).  Close 
the  abdominal  wound  with  silkworm-gut  sutures,  leaving  a  point  at  the 
lower  end  unclosed,  through  which  a  strip  of  gauze  is  passed  to  drain  the 
prevesical  space.  The  epipubic  notch  is  a  sure  guide  to  the  median  line 
below,  and  can  be  located  through  a  small  incision  of  the  superficial  tissues 
in  all  cases. 

The  Precautions. — The  prevesical  adipose  tissue  should  be  treated  kindly 
to  prevent  suppuration,  urinary  infiltration,  etc.  The  author  has  practiced 
a  free  smearing  of  the  wound  with  iodoformized  vaseline  in  such  cases  with 
satisfactory  results.  Glandular  enlargement  contraindicates  extensive  opera- 
tion on  the  bladder  for  removal  of  malignant  disease.  When  the  urine  is 
sterile,  the  bladder  healthy,  the  wound  small  and  closed  completely,  per- 
manent closure  of  the  vesical  and  abdominal  wounds  with  continuous  calhe- 
terism  are  indicated.  If  the  reverse  be  present  drainage  should  be  provided 
at  the  seat  of  the  wound.  In  all  instances  careful  scrutiny  should  be  exer- 
cised to  detect  urinary  infiltration  and  forestall  its  evil  effects. 

The  Resnlts. — ButJin  reports  57  cases  of  partial  cystectomy  with  16  deaths ; 
10  of  complete,  with  4  recoveries  ;  more  fatal  in  men  than  women  (page  1150). 

Drainage  of  the  Bladder. — The  bladder  may  be  drained  after  operation, 
in  three  ways :  First,  by  a  catheter  passed  through  the  urethra  and  retained 
there;  second,  by  a  tube  introduced  through  the  perinEeuni;  third,  by  a 
tube  or  tubes  introduced  through  the  suprapubic  wound. 

Vesical  Drainage  per  Urethrani.  —  This  method  of  drainage  is  only 
applicable  in  cases  in  which  drainage  is  required  for  a  short  time.  It  is 
77 


1124:  OPERATIVE   SURGERY. 

rarely  that  the  catheter  can  be  retained  more  tlum  three  or  four  days  without 
causing  more  or  less  serious  inconvenience.  Many  patients  can  not  tolerate 
the  presence  of  the  retained  catheter.  This  method  may  be  used  to  advan- 
tage in  such  cases  as  amputation  of  the  penis  and  in  certain  cases  of  en- 
larged prostate  in  old  men  who  have  become  accustomed  to  catheter  life. 
In  these  latter  cases  it  is  sometimes  useful,  when  the  calls  to  micturate  are 
frequent,  to  introduce  a  tie  in  or  a  clamp  catheter  at  night,  thereby  giving 
the  patient  a  chance  to  sleep.  To  be  etfective,  the  retained  catheter  must 
be  carefully  and  accurately  adjusted,  and  fastened  securely  so  as  to  prevent 
slipping. 

A  soft-rubber  catheter,  size  Xo.  12  F.,  with  velvet  eye  situated  as  near  the 
extremity  as  possible,  and  without  a  cul-de-sac,  is  sterilized  by  boiling,  and  is 
introduced  so  that  the  eye  is  just  within  the  bladder.  If  the  catheter  is  too 
far  in  the  bladder  it  is  certain  to  cause  painful  vesical  contraction ;  if  it  is 
not  introduced  far  enough  the  urine  will  not  flow  through  it.  If  the  blad- 
der be  emptied  by  a  catheter  and  a  boric-acid  solution  be  substituted  for  the 
nrine,  and  the  catheter,  while  being  slowly  withdrawn,  is  arrested  and  fastened 
just  before  the  fluid  ceases  to  flow,  it  will  be  suitably  located.  With  aseptic 
care  continuous  catheterism  may  be  kept  up  from  one  to  three  weeks  with 
comparative  comfort  and  no  danger.  However,  if  urethritis  arise,  causing 
much  infliction,  drainage  of  another  form  should  be  substituted.  At  first 
relief  may  be  afforded  in  these  cases  by  flushing  the  anterior  urethra  with  a 
Avarin  boric-acid  solution.  After  accurate  adjustment,  the  catheter  is  prop- 
erly secured  (Fig.  1311),  and  the  end  of  the  catheter  or  a  rubber-tube  attach- 
ment is  submerged  in  a  bottle  or  urinal,  containing  an  antiseptic  solution, 
placed  between  the  patient's  thighs  as  he  lies  in  bed.  "When  this  method  of 
drainage  is  used  the  catheter  should  be  changed  daily  and  replaced  by  a 
new  one,  or,  if  the  same  catheter  be  used  again  it  should  be  resterilized  by 
boiling.  Whenever  catheter  drainage  is  used  the  bladder  should  be  washed 
out  at  least  once  a  day  with  a  hot  sterile  borax  solution. 

Perineal  Drainage. — Perineal  drainage  may  be  employed  after  all  opera- 
tions upon  the  bladder,  prostate,  and  deep  urethra,  or  in  cases  of  severe  cysti- 
tis in  which  it  is  desirable  to  give  the  bladder  rest.  The  membranous  por- 
tion of  the  urethra  having  been  opened  through  the  perinfeum,  the  finger  is 
introduced  through  the  prostatic  urethra  into  the  bladder.  The  stretching  of 
the  prostatic  urethra  by  the  finger  greatly  lessens  the  pain  felt  at  the  end  of 
the  penis  experienced  by  cases  where  the  drainage  tube  is  retained.  A  rubber 
catheter,  size  No.  26  to  30  F.,  with  a  large  eye  near  the  end,  and  without  a 
cul-de-sac,  and  with  a  wide  lumen,  is  introduced  into  the  bladder  and  adjusted 
so  that  the  eye  is  just  within  the  bladder ;  the  adjustment  should  be  made 
with  the  patient's  thighs  on  the  same  plane  as  the  body.  The  instrument  is 
secured  in  place  by  tapes  which  are  tied  about  it  as  near  to  the  perineal  wound 
as  possible,  and  are  then  brought  up  and  secured  to  a  waistband.  A  dressing 
of  gauze  pads,  perforated  to  admit  passage  of  the  catheter,  is  made  and  secured 
by  a  T  bandage.  After  the  patient  is  in  bed  the  end  of  the  catheter  is  con- 
nected to  a  long  piece  of  rubber  tubing  having  a  glass  funnel  at  its  extremity, 
and  the  tube  and  funnel  having  been  filled  with  water,  the  latter  is  sunk  in 


OPERATIONS   OX   TIIK    IIMNAKV    ilLADDKi;. 


1125 


a  vessel  placed  on  the  lloor  uiuUt  the  bod,  or  in  it  (Fit:.  I')]')),  mul  con- 
taining u  solution  of  bichloride,  1  to  2,000. 

The  bladder  can  be  washed  out  as  often  as  necessary  by  disconnecting 
the  siphon  tube  and  injecting  the  fluid  carefidly  through  the  catheter  by 
means  of  a  Politzer's  bag  or  a  carefully  adjusted  syringe. 


Fig.  1315. — Harrison's  method  of  perineal  drainage.     P.  Enlarged  prostate. 
Antiseptic  solution  in  bottle. 

The  tube  should  be  taken  out  every  two  or  three  days,  sterilized,  and  re- 
introduced. This  method  of  drainage  is  the  best  in  most  cases,  and  may  be 
continued  for  many  weeks,  if  necessary. 

Suprapubic  Drainage. — Suprapubic  drainage  of  the  bladder  after  supra- 
pubic cystotomy  will  depend  upon  the  condition  for  which  it  is  emj^loyed 
and  the  probable  time  for  which  the  tube  will  be  retained. 

In  operations  where  there  has  been  little  hjemorrhage  the  bladder  may 
be  drained  by  a  single  tube.  Where  there  is  a  possibility  of  a  single  tube 
becoming  plugged,  either  by  blood  clot  or  by  masses  of  muco-pus,  two  tubes 
should  be  employed.  The  tubes  should  be  of  red  rubber,  flexible,  and  about 
twenty  inches  in  length  ;  the  best  size  is  about  26  F.  The  vesical  end  of 
the  tube  should  be  cut  obliquely,  and  the  sharp  end  trimmed  smooth ;  a 
large  fenestrum  should  be  cut  in  the  side  near  the  extremity  of  the  tube. 

When  a  single  tube  is  used  it  is  passed  into  the  bladder  so  that  its  end 
.nearly  reaches,  but  does  not  touch,  the  lowest  part.  A  safety  pin  is  then 
passed  through  its  wall  at  the  skin  level.  The  bladder  wound  is  sutured 
with  chromicized  catgut  up  to  the  tube,  care  being  taken  that  no  stitch 
passes  through  the  mucous  membrane.  The  outer  wound  is  then  united  by 
deep  silkworm-gut  sutures.     The  dressing  consists  of  a  pad  of  gauze  per- 


1126 


OPERATIVE   SURGERY. 


Fig.  1316. — Drainage  of  the  bladder,  Gibson's  method.  Tube 
inserted  and  stitches  employed  to  diminish  size  of  open- 
ing. 


forated  to  admit  the  tube,  and  close  to  this  another  safety  pin  is  passed 

through  the  wall  of  the  tube ;   the  pins  prevent  the  tube  from  slijiping. 

Gauze  pads  are  then  applied  and  hold  in  ])lace  by  strips  of  adhesive  plaster. 

The  tube  is  then  attached  to  a  siphon  apparatus,  as  already  described.     This 

plan  of  drainage  is  highly  commended  by  Alexander. 

Tlie  Remarhs. — When  suprapubic  drainage  is  used  after  operations  upon 

the   bladder  which  are  likely  to  be  followed    by  haemorrhage,  it  is  better 

to   employ   two    tubes. 

These   are  adjusted  in 

the    same    manner    as 

has      been      described 

above.     The  siphonage 

appliance  is  attached  to 

the  lower  tube  and  the 

upijer   one   is  clamped 

by  a  pinch  forceps.   The 

bladder  can  be  washed 

by  injecting  fluid  into 

one   of    the   tubes,  the 

wash  flowing  out  of  the 

other.     Stripping  of  the  tube  with  the  thumb  and  finger  may  be  needed  to 

eliminate  the  air  when  the  siphonage  is  broken. 

Gibson's  Method  of  Drainage. — Gibson,  noting  the  excellent  practical  out- 
come of  Kader's  method  of  gastrostomy  (page  751)  in  controlling  the  open- 
ing into  the  stomach, 
applied  this  practice  to 
drainage  of  the  blad- 
der with  commendable 
results. 

The  Operation. — A 
rubber  tube  (32  F.)  is 
passed  into  the  bladder 
through  a  snug-fitting 
opening,  and  the  blad- 
der wall  is  brought 
closely  around  it  by 
passing  through  the 
wall  at  either  side  (Fig. 
131 G)  of  the  tube  a 
Lembert  suture.  The 
first   of    the    inversion 

sutures  are  then  introduced  (Fig.  1317).     These  sutures  are  tied,  cut  short, 

and    "a  second  set  is  applied  and  tied   (Fig.   1318),  thus   increasing   the 

depth  of   the  burial  of   the  tube  in  the  wall"  (Fig.  1319).      The  tube  is 

then  secured  in  place  by  a  catgut   suture  connecting  it  with  the  bladder 

wall.     The  ends  of  the  second  set  of  sutures  are  left  long  and  utilized  in 

the  closure  of  the  abdominal  wound  snugly  around  the  tube.      "  Perfect 


Fig.  1317. — Drainage  of  the  bladder,  Gibson's  method. 
set  of  inversion  sutures  in  place  ready  for  tying. 


First 


Ul'KliATlUN'S   UN    TIIK    L'RlNAliV    HLADDKK. 


1127 


Fig.  1318. — Drainage  of  the  bladder,  Gibson's  method, 
set  of  sutures  tied,  second  in  place  for  tying. 


First 


drainage  is  effeotiHl  by  loadiii<:j  tlie  tube  into  a  recejjtaclc,  wliicli  need  not 
be  tilled  witii  lluitl  of  any  kind."  On  removal  of  the  tube  the  artificial 
o])eninf^  is  guarded  by  the  valve  arrangement  of  the  infolded  bladder  wall, 
whieh  is  readily  pushed 
asiile  by  the  catheter 
employed  in  relieving 
the  bladder,  without  the 
annoyance  of  subse- 
quent leakage.  It  ap- 
pears to  the  writer  that 
this  simple  method  af- 
fords a  great  advance 
in  etfeetive  bladder 
drainage  in  either  acute 
or  chronic  requirement. 
Dawbarn's  Appara- 
tus for  Bladder  Drain- 
age.— This  plan  of  ac- 
tion is  based  on  the 
old  principle  of  inter- 
mittent siphonage,  an  idea  of  respectable  age  and  useful  employment  (Fig. 
1320).  The  following  is  substantially  a  statement,  made  by  Dawbarn,  of 
the  apparatus : 

"  d  indicates  the  clamp  which  comes  with  every  fountain  syringe.  It  has 
been  removed  from  the  end  and  snapped  upon  the  side  of  the  tube,  so  as 
almost  to  close  it,  permitting  flow  only  drop  by  drop.  Forcipressure  may  be 
employed  instead. 

"  a  indicates  the  joint  between  two  or  three  pieces  of  rubber  tubing.  The 
simplest  way,  if  one  has  a  glass,  metal,  or  vulcanite  T  tube,  is  to  use  it  in  mak- 
ing the  connection.  But  if  not,  the  joint  is  made  as  follows  :  Cut  out  a  circle 
from  the  side  of  the  exit  tube  from  the  bag.  Sew  the  end  of  the  other  tube 
to  the  edges  of  this  small  hole.     Make  the  joint  tight  with  rubber  cement 

(made  by  dissolving  gutta- 
percha tissue  in  chloroform  to 
saturation),  and  strengthen  the 
union  by  wrapping  around  it 
narrow  strips  of  rubber  adhe- 
sive plaster. 

"  b  indicates  a  trap  which  is 

absolutely  essential.  The  trap  of 

the  main  exit  tube,  three  inches 

across,  is  formed  by  knotting 

Fic,.1319.— Drainage  of  the  bladdor.Gibson's  method.    (.^S  in  the  sketch)  or  bv  snap- 

Longitudinal  section,  showing  bladder  infolded      .  alnstie  band  -iround 

by  two  sets  of  sutures.  V^^^  Oil  ^^^  elastic  Dana  ai  ounu 

a  loop  of  the  tube. 
"  e  indicates  an  ajjparatus  introduced  to  collect  urine  (page  1128);  a  small 
piece  of  glass  tubing  a  couple  of  inches  long  is  employed  when  the  apparatus 


1128 


OPEILVTIVK   SURGERY. 


is  not  in  use.  The  device  operates  as  follows  :  tlie  water  trickles  down  from 
the  reservoir  until  the  trap  [b)  becomes  filled  ;  when  overfilled  it  siphons  off 
with  a  rush.     This  in  turn  makes  a  partial  vacuum  above  the  trap,  which  is 

filled  by  the  drawing  up  of  the  urine  in  the 
bladder,  thus  forming  a  second  siphon, 
causing  the  fluid  to  run  freely  from  the 
bladder  until  it  is  empty. 

"  This  process  of  intermittent  siphon- 
age  repeats  itself  at  regular  intervals  of  any 
desired  frequency.  As  a  rule,  if  the  flow 
from  the  reservoir  be  no  faster  than  from 
one  to  two  drops  per  second,  this  will  suf- 
fice to  prevent  a  bladder  from  overfilling. 
And  at  tliis  rate  of  flow  it  is  not  necessary 
to  replenish  the  bag  of  the  fountain  syr- 
inge oftener  than  once  in  several  hours. 

"  Usually,  a  Xo.  20  to  24  F.  soft  cathe- 
ter (c)  is  carried  through  the  supra- 
jDubic  wound  to  the  bottom  of  the  blad- 
der. The  catheter,  like  a  stomach  tube, 
should  have  two  openings  below,  a  second 
opening  being  cut  opposite  the  original 
one,  thereby  preventing  obstruction  from 
the  sucking  in  of  a  fold  of  mucous  mem- 
brane. At  the  point  of  escape  from  the 
bladder  the  tube  is  fastened  to  the  dress- 
ings with  a  safety  pin. 

"  Should  washing  out  of  the  bladder 
be  desired,  it  is  easily  done  without  dis- 
turbing the  w'ound.  Take  off  the  clamj) 
(d)  and  pinch  the  tube  tightly  below  a. 

"  The  contents  of  the  fountain  syringe 
will  then  run  freely  into  the  bladder. 
Cease  pinching  below  a,  close  the  tube  at 
(/,  and  the  fluid  will  run  by  siphonage 
out  of  the  bladder  into  the  bucket  below. 
"  Sometimes  it  is  desirable  to  know 
the  exact  amount  and  the  appearance  of 
urine  drained  away  ;  also  we  may  wish  to 
analyze  that  urine  undiluted  by  fluid 
from  the  reservoir. 

"  Then  insert  in  a  break  (e)  at  any  point 
in  the  tube  leading  from  the  bladder  the  chemist's  wash  bottle  with  its  usual 
equipment — a  tight-fitting  rubber  stopper  and  two  glass  tubes — thus  the  urine 
can  be  collected  and  the  amount  and  characteristics  can  be  determined." 

The  Remarks. — The  catheter  (c)  is  passed  through  a  brief  segment  (/)  of 
rubber  tubing,  which  latter  just  enters  the  bladder,  and  is  fastened  to  the 


Fici.  Io20. — Dawbarn's  apparatus  for 
bladder  drainage.  a.  Point  of 
junction  of  tubes,  h.  Knot  trap 
in  main  tube.  c.  Opening  in  end 
of  tube.  d.  Forcipressure  Hinit- 
ing  lumen  of  tube.  e.  ("liemist's 
wash  bottle.  /.  External  segment 
of  rubber  tubing  through  which 
catheter  passes  into  bladder. 


Oi'EKATlUNS   ON   TUK    UlilNAKV    ULADDKIl. 


1129 


central  tube  with  a  stitch,  and  is  lield  in  place  by  another  stitch  connected 
to  the  ]ilaster  dressing  of  the  wound.  Air  can  ])ass  between  the  tubes.  If 
the  urine  \>e  thick  a  larger  catheter  (No.  ;)()  F.)  should  be  employed. 

Artificial  Urethra  in  Prostatic  Obstruction. — The  formation  of  a  so-called 
artilicial  urctiira  above  the  pubes  in  cases  of  obstinate  prostatic  obstruction  is 
a  measure  of  important  moment  in  many  instances  attended  with  septic  inflam- 
mation of  the  bladder.  After  thorough  attention  to  aseptic  details  directed 
to  the  seat  of  the  operation  and  to  the  vesical  cavity,  cause  the  elevation  of 
the  bladder  above  the  pu])os  by  the  careful  em])loyment  of  the  rectal  bag  and 
vesical  injection,  as  in  suprapubic  cystotomy  (Figs.  14U7,  1408,  and  1409). 

'The  Operation. — Make  a  vertical  incision  in  the  median  line  three  or 
four  inches  in  length  through  the  integument  and  fascia}  down  to  the  upper 
border  of  the  symphysis 
pubis ;  expose  and  di- 
vide by  a  shorter  inci- 
sion the  linea  alba  verti- 
cally down  to  the  pubes ; 
separate  the  recti  mus- 
cles in  the  median  line 
and  divide  the  fascia 
transversalis  for  two 
inches  in  length  down 
to  the  pubis ;  expose  the 
bladder  by  careful  inci- 
sion and  displacement  of 
the  prevesical  cellular 
tissue,  leaving  that  part 
behind  the  pubes  undis- 
turbed ;  catch  the  ex- 
posed area  of  the  blad- 
der with  a  tenaculum 
and  pull  the  viscus  for- 
ward into  the  wound ; 
open  the  bladder  in  the 
median  line  opposite  the 
upper  border  of  the 
pubes  with  a  scalpel  suf- 
ficiently to  admit  the  in- 
dex   finger  ;     introduce 

through  the  abdominal  opening  into  the  bladder  a  Xo.  10  or  VI  E.  soft-gum 
catheter ;  close  the  bladder  and  the  abdominal  wound  around  the  catheter 
at  the  lower  and  the  abdominal  wound  at  the  upper  end  with  sutures ; 
pass  tlie  catheter  ni:)ward  against  the  rectus  and  unite  over  it  with  deep 
silkworm-gut  sutures  the  borders  of  the  wound  so  as  to  form  a  fistulous 
communication  with  the  bladder  three  or  four  inches  in  length  ;  connect 
the  distal  end  of  the  catheter  by  a  tube  with  a  receptacle  of  aseptic  fluid 
placed  at  the  side  of  the  patient. 


c  \ 


Fig.  1321. — Operation  for  artificial  urethra.  Morris's  method. 
a.  Aponeurosis  of  external  oblique,  b,  b.  Flaps,  c,  c. 
Outlines  of  displaced  flaps. 


1130 


OPERATIVE  SURGERY. 


The  Comments. — If  vesical  tenesmus  follow,  the  catheter  should  be 
removed  and  the  drainage  wick  substituted.  The  urine  is  kept  acid,  absorb- 
ent cotton  applied  as  often  as  needed,  the  psitient  kept  in  bed,  and  continu- 
ous urethral  catheterism  maintained  if  danger  of  urinary  infiltration  be 
apprehended.  McGwire  punctured  the  bladder,  established  a  fistula  with  it, 
and  regulated  the  discharge  of  urine  by  fitting  to  the  fistula  a  silver  plug 
held  in  place  by  a  belt  worn  around  the  hips. 

The  Results. — The  functional  use  of  the  sinus  urethra  is  quite  satisfac- 
tory in  all  respects.     The  intervals  between  the  acts  of  micturition  vary 


*^*f?^ 


Fig.  1322.  Fig.  1323. 

Fig.  1322. — Operation  for  artificiul  urethra,  Morris's  method,     c,  c.  Fhips  turned  inside. 
Fig.  1333. — Operation  for  artificial  urethra,  Morris's  metliod.  Wound  closed,   showing 

orifice  in  lower  end. 


from  two  to  six  hours,  and  are  not  attended  with  discomfort,  and  the  dis- 
charge of  the  urine  is  free  and  pronounced.  Cicatricial  narrowing  is  some- 
times excessive  and  objectionable. 

Morris''s  Modification  of  McGuire's  Operation. — Morris  proceeded  after 
the  manner  of  McGuire  in  exposing  and  opening  the  bladder.  However,  he 
temporarily  stitched  the  bladder  to  the  abdominal  wall  while  preparing  and 
attaching  to  the  incision  in  the  bladder  the  two  skin  flaps  that  constitute 
the  modification.  A  skin  flap  a  third  of  an  inch  in  width  and  about  three 
inches  in  length,  including  the  fat  and  subcutaneous  tissue,  is  dissected 
from  either  side  of  the  abdominal  incision  and  remains  attached  below 
(Fig.  1321).  The  free  ends  are  turned  inside  so  as  to  bring  their  cutaneous 
surfaces  in  contact  with  each  other,  and  each  extremity  is  sutured  to  the 
mucosa  of  the  bladder  at  the  respective  side  of  the  incision  (Fig.  1322). 


()|'|-:ka'I"1(»ns  ox  'riii:  i  Kl.^Al;^    I'.i,a1)I)i;k.  n^i 

Tlie  retonlioii  sutures  arc  ihvn  cut,  and  as  thu  IjhuMcr  recedes  the  cutaneous 
flaps  aro  drawn  into  position.  Tlio  npper  portion  of  the  wound  is  closed  in 
tlie  usual  numner  (Fii,^  i;5"^';5).  Aristol  is  rubhed  into  tli((  wound  to  lessen 
the  danger  of  urinary  inliltration,  aiul  the  urine  withdrawn  by  the  drainage 
wick  with  one  end  in  the  l)laddi'r  and  tlu!  otlu'r  lying  on  the  aljdornen. 

This  nu)di(ication  aims  to  establish  a  sinus  with  a  cuticular  lining  and  to 
secure  the  benefits  of  such  a  ])rovision.  Morris  now  regards  it  advisable  to 
make  the  lla})s  wider.  Moullin  employed  the  llajis,  leaving  them  attached  at 
the  upper  instcatl  of  the  lower  end  in  order  that  he  might  establish  a  larger 
urethra.  The  plan  answered  well  at  first,  but  soon  obstruction  occurred  in 
the  passage  at  the  junction  of  the  cutaneous  and  mucous  structures,  which 
was  a  source  of  much  annoyance.  The  patient  could  retain  the  urine  for 
three  or  four  hours,  and  expel  it  guided  aw^ay  from  the  body  by  a  tube  placed 
at  the  orifice.  Gibson\^  method  of  drainage  bids  fair  to  eliminate  these  more 
complicated  operations  from  the  needs  of  surgical  technique. 

Prostatectomy. — Prostatectomy  is  an  operation  devised  for  the  removal 
of  all  or  a  ])art  of  the  hypertrophicd  portion  of  the  prostate  to  secure  relief 
from  the  following  conditions  : 

1.  When  there  is  complete  or  almost  complete  retention  of  urine  due  to 
prostatic  outgrowths  about  the  internal  urethral  orifice  or  projecting  into  the 
prostatic  urethra,  making  the  patient  entirely  dependent  at  all  times  upon 
the  use  of  his  catheter.  The  consequences  can  not  be  doubtful  in  such 
cases,  and  operation  affords  the  only  means  of  averting  fatal  disaster. 

2.  When  there  is  marked  and  continuous  vesical  irritability  due  to  intra- 
vesical outgrowths  which  can  not  be  allayed  by  the  most  careful  catheterism 
and  washing  of  the  bladder.  These  patients  usually  suffer  from  frequent 
attacks  of  hajmaturia,  and  cystitis,  when  it  develops,  is  usually  severe. 

3.  When,  in  spite  of  careful  catheterism,  tlie  amount  of  residual  urine  is 
steadily  and  surely  increasing,  showing  a  gradual  failure  of  expulsive  force  in 
the  bladder. 

4.  When  catheterism  is  becoming  more  and  more  difficult  in  spite  of  all 
precaution,  and  when  it  is  frequently  followed  by  haemorrhages. 

5.  When  catheterism,  in  spite  of  all  precaution,  is  frequently  followed  by 
attacks  of  cystitis. 

G.  In  cases  of  long-continued  vesical  inflammation  which  do  not  yield  to 
treatment. 

7.  In  cases  in  which  the  patients  can  not  or  will  not  use  a  catheter  and 
take  the  necessary  aseptic  precautions  to  make  its  use  of  value. 

In  a  word,  it  may  be  stated  that  catheterism,  with  all  that  the  term 
implies  in  the  treatment  of  prostatic  enlargement,  should  be  employed  in 
all  cases  until  it  fails  to  give  relief;  but  that  when  it  fails,  and  the  integrity 
of  the  bladder  and  kidneys  is  threatened,  we  should  resort  to  operative  treat- 
ment before  these  organs  have  become  hopelessly  damaged  (Alexander). 

Two  routes  of  approach  to  the  prostate  are  practiced  :  the  perineal  and 
suprapubic  routes.  Two  methods  of  procedure  are  advised  in  connection 
with  the  former  route;  one  in  which,  after  a  perineal  section,  the  growth  can 
be  reached  with  the  finger,  and  on  account  of  its  small  size,  limited  attach- 


1132 


OPERATIVE   .SUKGEUY. 


ment,  and  accessibility,  can  be  readily  removed  through  the  perinaeum  with 
forceps  and  punches.  Gouley  i)racticed  this  method  with  signal  success 
before  and  since  1885.  This  class  of  cases  is  comparatively  infrequent,  and 
though  temporarily  relieved  by  the  treatment  without  especial  danger  to  the 
patient,  may  soon  again  cause  renewed  affliction  by  continued  growth.  The 
outcome  of  this  partial  method  of  prostatectomy  emphasizes  the  utility  of 
the  complete  methods.  The  complete  methods  are  applied  to  the  organ 
above  or  below  the  pubis,  as  suits  the  nature  of  the  case  and  the  inclination 
and  ex})('ri('iice  of  the  o})C!rator. 

Suprapubic  Prostatectomy  (McGill). — Shave  the  pubis,  scrub  and  wash 
the  parts  thoroughly ;  irrigate  the  bladder  with  the  boric-acid  solution,  leav- 
ing a  considerable  portion  (6  to  10  ounces)  of  the  fluid  in  the  viscus ;  intro- 
duce the  rectal  bag  above  the  sphincters  (page  1407)  and  distend  it  moder- 
ately (6  to  10  ounces). 

Tlie  Operation. — Expose  and  open  the  bladder  as  in  suprapubic  cystotomy 
(page  1115) ;  sew  the  borders  of  the  opening  to  those  of  the  abdominal  wound 
with  catgut;  place  the  patient  in  the  Trendelenburg  position  and  expose  the 
prostate  to  jjalpation  and  inspection  by  means  of  retractors  and  a  strong 
light ;  incise  the  mucous  membrane  covering  sessile  growths,  and  enucleate 
the  growths  through  the  opening  with  the  finger,  aided  by  the  curette  or 
curetting  forceps  when  required;  sever  pediculated  tumors  at  the  base  with 

curved  scissors  and  remove  the  growth  ; 
divide  the  collarlike  growths  into  halves 
by  cutting  above  and  below  the  vesical 
orifice  with  scissors  and  follow  by  enuclea- 
tion. The  portion  of  the  gland  projecting 
into  the  bladder  is  cut  in  halves  and  each 
is  separately  enucleated  and  removed.  Cut- 
ting should  be  avoided  on  all  occasions 
when  the  same  result  can  be  accomplished 
by  enucleation.  The  haemorrhage  is  usual- 
ly quite  free,  and  promptly  obscures  the 
process  of  enucleation  from  observation. 
It  is  sometimes  severe  and  may  be  even 
dangerous,  requiring  especial  attention  to 
prevent  undue  loss  of  blood.  Hot  water 
applied  directly  to  the  part  with  sponges  or 
gauze,  which  are  held  firmly  in  place  for  a 
time,  will  usually  suffice  to  arrest  the  flow. 
Informal  packing  with  gauze,  or  the  use  of 
the  gauze  tampon  devised  by  Keyes  (Fig. 
1321),  or  that  of  Cabot  (Fig.  1325)  may  be 
required  to  arrest  haemorrhage.  Keyes  thus 
describes  his  tampon :  "  The  tampon  is 
made  of  bichloride  gauze.  A  square  of  four  thicknesses  of  gauze  is  first  cut, 
the  length  of  each  side  being  about  six  inches.  Upon  this  are  placed  eight 
thicknesses  of  gauze  cut  square,  each  side  measuring  four  inches,  and  upon 


e; 


Fig.  1324. — Keyes's  tampon  in  supra- 
pubic prostatectomy. 


Ol'KKATlUNS   (J.N    TllK    LltlNAUV    iJLADDKU. 


1133 


tliis  ciglit  other  thicknesses  of  gauze,  also  s(|uarc,  tlio  sides  measuring  tliree 
inches.  Contnilly,  upoTi  the  tiiree-inch  pad,  a  small  white  shirt  button  is 
tied  by  a  stout  silk  ligature,  transfixing  the  pad  and  tied  upon  the  six-inch 
square  surface.  This  central  button  also  has  a  piece  of  silk  attached  to  it, 
running  out  freely  in  the  direction  away  from  the  three-inch  surface.  This 
is  to  facilitate  extraction.  Each  of  the  cor- 
ners of  the  six-inch  pad  is  stoutly  tied  with 
a  piece  of  silk,  and  tiie  silk  from  each  of 
these  four  corners  is  knotted  at  its  end 
into  a  double  knot,  while  the  silk  running 
out  backward  from  the  button  is  tied  with 
a  single  knot,  for  the  purpose  of  distin- 
guishing which  is  which  when  making  the 
extraction ;  although  practically  it  will  be 
found  that  they  must  all  be  made  taut  and 
pulled  upon  all  together  in  order  to  eifect 
removal  with  the  greatest  ease  and  facility." 
This  tampon  is  applied  through  the  supra- 
pubic opening  to  the  bleeding  surface,  and 
held  firmly  in  place  by  a  cord  attached  to 
it  and  passed  through  a  perineal  opening  of 
the  urethra  and  secured  externally  by  a 
roll  of  gauze.  The  tampon  is  rarely  re- 
tained longer  than  twenty-four  hours.     The 

bladder  is  drained  through  the  suprapubic   -c     .onn     r.  u  4.>  4.  t 

^    .  ^^  Fig.  1325. — Cabot  s  tampon  for  supra- 

opening  by  one  of  the  various  methods  of  pubic  prostatectomy. 

drainage  already  described.     Frequent  and 

sometimes  continuous  irrigation  of  the  bladder  is  practiced  for  a  few  days. 

The  construction  of  Cabot's  tampon  is  explained  by  the  illustration. 

The  Comments. — Prostatectomy  should  not  be  practiced  hastily,  but 
rather  during  a  quiescent  state  of  the  disease,  if  possible,  to  avoid  undue 
hemorrhage  and  reaction.  It  is  wise  in  severe  and  offensive  cases  to  estab- 
lish preliminary  drainage  of  the  bladder  for  a  time  before  attempting  pros- 
tatectomy, thus  dividing  the  procedure  into  two  stages — preliminary  and 
final.  If  the  bladder  be  much  contracted,  its  distention  so  as  to  appear 
above  the  pubis  may  be  attended  with  not  a  little  danger  of  rupture. 
However,  vesical  distention  and  peritoneal  elevation  are  of  less  operative 
importance  than  is  the  support  given  the  prostate  by  the  distended  bag. 
The  opening  into  the  bladder  is  made  at  the  most  prominent  portion  of  the 
anterior  surface,  and  should  be  large  enough  at  first  to  admit  the  index  fin- 
ger readily.  Fuller  exposes  the  prostatic  structure  with  scissors,  inserts  the 
fingers  into  the  incision  and  enucleates  the  growth,  while  firm  upward  pres- 
sure is  made  on  the  perineum.  Suprapubic  and  infrapubic  drainage  is 
then  established.  He  advises  that  the  incision  of  the  mucous  membrane 
covering  the  enlargement  be  made  as  small  as  is  consistent  with  a  proper 
enucleation  with  the  fingers.  If  the  prostate  be  fibrous  and  hard,  enucleation 
will  be  very  difficult,  if  not  impracticable,  and  cutting  with  biting  forceps 


1134  OPERATIVE   SURGERY. 

must  be  employed  instead  for  the  removal.  While  a  practical  success 
depends  on  the  complete  removal  of  the  growth,  still,  the  amount  removed 
should  be  measured  by  the  demands  of  the  case.  Posterior  and  lateral 
encroachment  of  the  growth  on  the  canal  should  be  removed  so  as  to  form 
a  funnel-shaped  orifice  with  a  low  and  level  urethral  floor  at  the  prostatic 
opening.  Drainage  of  the  prostatic  portion  of  the  urethra  is  best  made 
through  the  perina^um,  as  suprapubic  drainage  is  better  adapted  to  intra- 
vesical operations.  A  perineal  incision  provides  not  only  drainage,  but  the 
opportunity  to  support  the  prostate  body  during  its  removal.  Suprapubic 
entrance  is  not  admissible  for  the  purpose  of  prostatectomy  when  the  bladder 
is  contracted  to  a  small  hard  sac.  Hard  prostates  yield  less  to  pressure  than 
the  soft,  and  therefore  they  require  less  rectal  distention.  A  suture  should 
be  introduced  at  the  lower  angle  of  the  abdominal  wound  to  lessen  the 
possibility  of  urinary  infiltration.  Introduce  the  finger  into  the  vesical  open- 
ing to  see  if  the  urethra  is  intact  before  leaving  the  wound.  Kilmmel  sutured 
the  bladder  and  drained  through  the  perineum  with  a  catheter.  Keyes  in 
dense  cases  at  the  neck  employed  the  rongeur  for  removal. 

The  Results. — Complete  cure  does  not  follow  the  operation  in  the  major- 
ity of  the  cases  of  recovery,  because  of  the  structural  changes  in  the  bladder. 
Therefore,  the  ultimate  prognosis  of  early  operations  is  better  than  those 
done  at  a  later  period.  In  6  only,  of  37  operations,  was  the  function  of 
micturition  restored  (Vignard).  Complete  functional  cure  is  limited  to 
less  than  25  per  cent  of  the  cases  of  recovery.  The  death  rate  is  from  18  to 
20  per  cent  for  all  operators  (Alexander).  Alexander  records  the  follow- 
ing objections  to  the  suprapubic  method  : 

"  1.  That  the  mucous  membrane  of  the  bladder  and  that  of  the  pros- 
tatic urethra  are  cut  through,  and  more  or  less  torn  and  bruised. 

"  2.  That  the  haemorrhage  is  frequently  severe,  and  requires  packing  of 
the  wound  to  control  it. 

"  3.  Another  and  still  more  vital  objection  to  these  methods  is  that,  after 
prostatic  obstruction  is  removed,  a  cavity  is  left  which  is  freely  accessible  to 
the  urine.  In  this  the  urine  collects,  and,  as  this  is  often  foul  in  the  cases 
operated  upon,  there  is  great  danger  of  septic  infection.  Nor  can  this  cav- 
ity from  which  the  prostate  has  been  removed  be  efficiently  drained.  Supra- 
pubic drainage  alone  is  entirely  inefficient,  and  even  when  perineal  drain- 
age is  employed,  the  tube,  in  order  properly  to  drain  the  bladder,  must  be 
placed  above  the  level  of  this  cavity." 

Perineal  Prostatectomy. — Small  median  tumors  and  portions  of  the 
lateral  lobes  can  be  reached  through  this  incision,  and  removed  by  means 
of  the  finger,  scissors,  forceps,  etc. 

The  Operation. — After  the  usual  preliminary  preparations,  place  the 
patient  in  the  lithotomy  position ;  introduce  a  staff  as  for  the  operation  of 
perineal  cystotomy ;  insert  the  left  index  finger  into  the  rectum,  and  steady 
the  beak  of  the  instrument  by  pressing  against  it  at  the  apex  of  the  pros- 
tate with  the  point  of  the  finger ;  thrust  a  narrow-bladed,  double-edged 
knife  into  the  median  rhaphe  half  an  inch  in  front  of  the  anus,  tilting  the 
staff  at  the  point  where  it  is  steadied  by  the  finger ;  incise  the  apex  of  the 


orKKATlOXS   UN    TlIK    I'ln.NAIJV    IJLADDKK 


1135 


prostate  and  open  the  prostatic  urethra  by  advuneiiif^  tlie  point  of  the  knife 
alon<;  tile  groove  in  tiie  stalf  as  tiie  i\nife  is  witlidrawn. 

The  Remarks. —  Watson  regards  the  method  favorably  for  jiartial  or  com- 
plete removal  of  intravesical  growths  in  two  thirds  of  the  cases.  If  the  })ros- 
tatic  nrethra  be  so  much  lengthened,  because  of  the  hypertrophy,  that  the  fin- 
ger is  not  available  for  exploration  purposes,  this  method  of  operation  should 
not  be  pi'acticed. 

Dittel's  Method  [Lateral  Prosfafertom//). — Dittel  recommends  removal 
of  either  lateral  lobe  of  an  enlarged  prostate  through  a  cuneiform  incision 
(Fig.  132G).  A  catheter  or  sound  is  introduced  into  the  bladder  througli 
the  urethra,  and  held  in  place  to  enable  the  surgeon  to  recognize  and  avoid 
the  urethra.  The  rectum  is  packed  with  gauze  to  secure  its  prompt  recog- 
nition and  consequent  safety.  The  patient  is  placpd  on  the  table,  the  back 
uppermost,  and  body  oblique  for  better  opportunity  of  breathing,  the  legs  of 
the  patient  hanging  over 
the  end.  An  incision  is 
made  from  the  tip  of  the 
coccyx,  down  the  median 
line  to  the  middle  of  the 
external  sphincter,  thence 
around  the  anus  nearly  to 
the  rhaphe  in  front.  The 
prostate  is  freely  exposed 
through  the  incision,  the 
capsule  incised,  and  the  en- 
largements are  removed, 
leaving  sufficient  tissue  to 
insure  the  urethra  from  in- 
jury. The  wound  is  then 
cleansed,  drained,  and  light- 
ly packed.  Several  success- 
ful cases  of  this  method  of 

practice  are  reported,  and  on  the  whole  it  is  entitled  to  favorable  considera- 
tion. Pi/le  gains  ready  and  uneventful  access  to  the  prostate  through  a 
perineal  incision  similar  to  that  employed  in  bilateral  lithotomy  (Fig.  14U2,(;). 
After  division  of  the  anal  fasciae  and  separation  of  the  fibers  of  the  levator 
ani  muscle,  the  prostate  is  exposed  and  enucleated. 

The  Combined  Method  (Belfield).— The  importance  of  the  combination 
of  perineal  and  suprapubic  manipulation  in  prostatectomy  was  first  noted 
by  Belfield.  However,  to  Nicoll  belongs  the  credit  of  maintaining  the  integ- 
rity of  the  mucous  membrane  of  the  bladder  at  the  base,  and  thus  preserv- 
ing the  perineal  wound  from  vesical  infection. 

The  Opera fion.~^npra\-mh\c  cystotomy  (page  1115)  is  first  performed. 
The  wall  of  the  bladder  is  secured  to  the  skin  by  five  sutures— one  at  the 
lower  angle — the  mucous  membrane  is  thoroughly  cleansed,  and  the  bladder 
cavity  is  partly  .filled  witli  carbolic  solution  (one  part  in  two  hundred). 
The  patient  is  then  placed  in  the  lithotomy  position,  and  a  sound  or  bougie 


Fig.  1326. — The  operation  of  lateral  prostatectomy, 
Dittel's  method.  Siring  attached  to  gauze  packing 
protruding  from  anus. 


1136  OPERATIVE  SURGERY. 

is  passed  into  the  bladder  and  given  to  an  assistant.  With  the  left  forefin- 
ger in  the  rectum,  an  incision  is  made  in  the  perineal  rhaphe  and  gradu- 
ally deepened  without  penetrating  the  urethra  or  the  bladder  until  the 
apex  of  the  prostate  is  reached.  The  rectum  is  carefully  separated  from 
the  posterior  surface  of  the  prostate,  and  a  vertical  incision  is  made  through 
the  posterior  and  inferior  part  of  the  prostatic  capsule.  The  capsule  is 
gradually  separated  from  the  gland  at  either  side  by  means  of  a  periosteal 
elevator  or  a  like  blunt  instrument.  The  assistant  meantime  is  pressing 
the  prostate  down  into  the  perineal  wound  with  his  fingers,  introduced 
into  the  bladder  through  the  suprapubic  opening.  (If  sufficient  room  for 
the  isolation  of  the  prostate  is  not  afforded  by  the  median  perineal  wound, 
additional  room  may  be  obtained  by  supplementing  the  median  incision  by 
a  lateral  one,  curved  outward  and  backward,  beginning  at  the  posterior  end 
of  the  median  cut  and  curved  outward  and  backward  to  a  point  between  the 
anus  and  the  posterior  part  of  the  tuber  ischium,  nearer  the  former  than  to 
the  latter.  This  incision  may  be  made  at  one  or  both  sides.)  All  bleeding 
points  having  been  secured,  the  surgeon,  after  carefully  Avashing  his  left 
index  finger  in  a  carbolic  solution,  puts  it  and  the  middle  finger  of  the  left 
hand  into  the  bladder  through  the  suprapubic  wound,  and,  wdiile  pressing 
the  prostate  down  into  the  perineal  wound,  removes  through  the  perina^um, 
with  the  fingers  of  the  right  hand,  the  entire  prostate,  or  as  much  of  it  as 
he  deems  necessary.  A  sufficient  amount  should  be  removed  to  relieve  the 
neck  of  the  bladder  from  pressure,  and  permit  the  bringing  down  of  the 
neck  to  a  level  with  the  post-prostatic  pouch  at  the  base  of  the  bladder. 
One  judges  of  the  amount  to  be  removed  by  manipulating  the  parts  between 
the  fingers  of  the  two  hands.  If  the  prostatic  tissue  proves  to  be  tougher 
and  more  resistant  than  usual,  the  fingers  of  the  right  hand  may  be  supple- 
mented by  the  careful  use  of  a  blunt  periosteal  elevator,  and  even  by  Volk- 
mann's  spoon.  During  the  entire  operation  neither  the  bladder  nor  the 
urethra  is  opened,  except  as  the  former  is  involved  by  the  suprapubic  incision. 
After  enucleation  is  completed,  the  instrument  is  withdrawn  from  the  blad- 
der and  a  large-eyed,  short-beaked  metal  catheter  (like  a  lithotrity  evacuat- 
ing catheter),  or  a  large  gum-elastic  caiheter  coude  is  introduced  and  tied 
in  place.  The  perineal  wound  is  douched  with  a  w^eak  carbolic  solution, 
carefully  dried  with  gauze  or  sponges,  and  firmly  stuffed  with  iodoform 
gauze.  The  five  stitches  in  the  suprapubic  wound  are  cut,  removed,  and  the 
bladder  is  permitted  to  drop  from  the  abdominal  wall. 

The  after-treatment  consists  mainly  in  douching  the  bladder  daily  through 
the  suprapubic  wound  with  boracic  fluid  or  a  weak  solution  of  carbolic  acid, 
which  escapes  through  the  catheter.  The  iodoform  packing  is  changed 
every  second  or  third  day  for  a  fortnight  and  then  discontinued  and  the 
wound  allowed  to  close.  The  suprapubic  wound  is  dressed  with  a  pad  of 
sublimated  gauze,  and  begins  to  close  about  this  time.  The  douching  then 
may  be  discontinued. 

The  comparative  advantages  of  this  method  of  prostatectomy  appear  to  be 
the  following  :  a.  The  hasmorrhage  is  much  less.  This  is  what  a  priori  might 
be  expected.     The  prostatic  plexus  of  veins  lies  on  the  surface  of  the  pros- 


OI'KIIATIOXS   ON    TIIK    UKINAKV    I'.I.A  DDIllt. 


Ii:i7 


tato,  and  is  therefore  eliielly  removed  along  with  the  capside.  Furthermore, 
the  plexus  is  ehielly  loeated  at  the  anterior  and  lateral  aspects  of  the  organ. 
In  approaehing  the  ])rostate  on  the  posterior  and  inferior  surfaces  but  few 
veins  ar(^  encountered,  h.  The  inliltration  of  freshly  wounded  tissues  by  the 
l)utrid  and  septic  urine  is  avoided.  In  adequate  removal  of  tiie  body  and 
lateral  lobes  a  large  ga[>ing  cavity  remains.  In  the  suprapubic  o[)eration 
no  etlicient  means  of  draining  this  cavity  is  known.  'I'he  depth  of  the  cav- 
ity in  these  cases  is  such  that  it  is  not  pi'operly  drained  tlirough  the  penis, 
and  the  fluid  remaining  behind  is  liable  to  decomi)ose,  which  can  not  occur 
in  this  method  of  oj)eration.  c.  The  operation  insures  adequate  removal  of 
the  obstructing  prostatic  tissue,  thereby  avoiding  a  chief  source  of  failure 
to  give  relief  peculiar  to  the  perineal  and  suprapubic  operations,  d.  The 
preservation  intact  of  the  bladder  wall  insures  less  risk  of  tearing  the  deep 
urethra,  and  therefore  chiefly  obviates  the  occurrence  of  the  serious  com- 
plications mentioned  above.  With  a  sound  in  the  urethra  and  the  fingers 
in  the  bladder  there  can,  with  care,  be  little  chance  of  removing  any  of  the 
bladder  or  urethral  wall  along  with  the  prostatic  tissue,  e.  The  absence  of  a 
perineal  tube  permits  the  patient  to  sit  from  the  first  without  inconvenience. 

Tlie  Remarks. — In  the  instances  of  median  lobe  involvement,  Nicoll 
advises  that  the  removal  of  this  portion  be  omitted  for  eight  or  ten  days, 
or  until  the  urine  is 
aseptic  and  the  peri- 
neal wound  is  covered 
with  granulation,  thus 
avoiding  iutlltration. 

The  Combined  Meth- 
od {Ale.vander). — The 
writer  desires  to  ac- 
knowledge his  obliga- 
tions to  Dr.  Alexander 
for  his  kindness  in  fnr- 
nisliing  the  following 
statement,  which  is 
quoted  in  full : 

"  The  object  of  this 
method     is    to    remove   Fig.  1827. — Transverse  section  of  enlarged  prostate  imme- 
those    portions    of    the  cliatelybehintl  openinij^s  of  seniinal  ducts.  ^  f/.^.^Enlarged 

enlarged  prostate  which 
cause  obstruction,  with 
as  little  injury  to  the 
urethra  and  bladder  as 
possible.  It  is  based  upon  the  following  anatomical  facts,  which  have  been 
demonstrated  by  the  writer:  1.  The  prostatic  urethra  may  be  divided  surgi- 
cally into  two  parts,  the  one  lying  above  the  openings  of  the  seminal  ducts 
(vesical  portion),  the  other  lying  below  the  seminal  ducts  (urethral  portion) 
(Fig.  1327).  The  walls  of  the  vesical  portion  of  the  prostatic  urethra  are 
comparatively  thick,  and  from  this  portion  of  the  urethra  the  prostate  may 


anterior  parts  of  lateral  lobes  (can  be  enucleated),  b.  En- 
larged posterior  part  of  lateral  lobes  (left  after  ennclea- 
tion).  4-  Upper  wall  of  urethra,  urethral  opening  ap- 
pearing as  a  vertical  slit,  with  the  vera  montanum  below, 
(From  Alexander's  collectiou.) 


113S  OPKRATIVE   SURGERY. 

be  easily  removed  without  injury  to  the  mucous  membrane.  Tlie  walls  of 
the  urethral  portion  of  the  prostatic  urethra  are  much  thinner  and  depend 
very  largely  for  their  support  upon  the  prostatic  tissue  which  surrounds  the 
canal.  2.  From  the  central  fibrous  jjortion  of  the  prostate,  which  lies  behind 
the  urethra,  there  extend  laterally  outward  strong  trabeculae  to  the  fibrous 


Fig.  V32>>. — L'Miffitiiilinal  seetinii  of  enhirijed  prostate  ami  part  of  posterior  wall  of  blad- 
der. (I.  Enlarged  anterior  part  of  left  lateral  lobe  (can  be  enucleated),  b.  Enlarged 
posterior  part  of  left  lateral  lobe  (left  after  enucleation),  c.  Seminal  duct.  d.  Pos- 
terior wall  of  bladder.     +  +  Line  of  prostatic  urethra.    (From  Alexander's  collection.) 

capsule  of  the  glaud.  These  trabecule  divide  the  lateral  lobes  into  two 
parts — viz.,  1,  a  portion  lying  in  front  of  these  trabeculae,  and  lying  at  the 
side  of  the  urethra ;  this  is  the  only  portion  of  the  lateral  lobe  which  by  its 
enlargement  causes  obstruction  to  urination  (Fig.  1328) ;  2,  a  portion  lying 
below  or  behind  these  trabeculae — that  is,  behind  or  below  the  urethra  and 
behind  and  below  the  seminal  ducts — never  is  by  its  enlargement  a  cause  of 
obstruction  to  urination  (Fig.  1329).  The  portion  of  the  lateral  lobe  which 
causes  obstruction  can  be  enucleated  en  masse,  leaving  the  posterior  portion 
of  the  lateral  lobe  and  the  capsule  intact.  The  fibrous  trabecule  mentioned 
above  form  the  line  of  cleavage  between  the  anterior  and  posterior  portions 
of  the  lateral  lobes. 

"  The  Preparation  of  the  Patient. — The  patient  is  prepared  as  for  any 
major  surgical  operation.  It  is  important,  when  possible,  to  devote  a  few 
days  before  the  operation  to  an  attempt  to  diminish  infection  of  the  bladder 
by  careful  catheterism  and  washing,  and  by  the  internal  administration  of 
full  doses  of  urotropin.  The  patient  being  etherized  the  bladder  is  emptied 
and  is  then  distended  with  a  sterile  salt  solution,  from  eight  to  ten  ounces 
being  sufficient  in  most  cases  to  bring  the  organ  well  above  the  pubes. 

'•  The  Operation. — The  bladder  is  exposed  in  the  space  of  Retzius  by  a 
vertical  incision  between  the  recti  muscles;  two  traction  sutures  are  intro- 
duced through  its  anterior  walls.  Between  these  sutures  an  opening  is 
made  into  the  bladder  large  enough  to  permit  the  operator  to  pass  his 
finger.  The  condition  of  the  bladder  and  the  intravesical  projections  of 
the  prostate  can  now  be  thoroughly  examined  by  digital  exploration.  The 
edges  of  the  bladder  wound  are  then  united  to  the  skin  by  a  single  temporary 


OPERATION'S   ON    TIIK    l'i:iNAI{V    I'.I.ADDHK. 


1139 


stitoh  oil  each  side.  'IMie  .siiitrapubic  opeiiiiif^  is  now  covered  with  gauze, 
and  tlio  patient  is  placed  in  the  litliotoiny  posture.  A  hroad,  median-grooved 
stall'  is  passed  into  the  bladder  and  held  by  an  assistant.  The  nienibranons 
urethra  is  opened  by  a  free  median  perineal  incision,  cutting  through  the 
floor  of  this  portion  of  tlie  urethra  from  just  behind  the  bulb  to  the  apex  of 
tlie  prostate.  The  o[)erator  introduces  his  llngei'  into  the  wound,  and  as  the 
statT  is  withdrawn  the  linger  is  passed  through  the  })rostatic  urethra  into  the 
bladder  for  the  purpose  of  dilating  the  canal.  The  operator  now  again 
washes  anil  disinfects  his  hands,  if  they  have  been  soiled.  He  then  passes 
the  forelinger  of  his  left  hand  through  the  suprapubic  wound  into  the 
bladder,  and  presses  the  prostate  downward  into  the  perinanim.  The  fore- 
finger of  his  right  hand  is  introduced  through  the  perineal  wound  into  the 
urethral  part  of  the  prostatic  urethra  and  begins  the  process  of  enncleation. 
This  is  i)crformed  as  follows :  The  operator  feels  in  the  lateral  wall  of  the 
prostatic  urethra  for  a  prominence  due  to  the  enlargement  of  one  of  the 
lateral  lobes,  and  breaks  through  the  mucous  membrane  immediately  in 
front  of  this  prominence.  As  soon  as  this  is  done  the  finger  passes  between 
the  antei'ior  and  posterior  portions  of  the  lateral  lobe  in  the  line  of  cleavage 
formed  by  the  fibrous  trabeculte  spoken  of  above.  The  obstructing  portion 
of  the  lateral  lobe  is  easily  separated  on  its  lateral  and  posterior  surfaces 
from  the  posterior  })art  of  the  prostate  and  its  capsule.  It  is  then  sep- 
arated from  the  mucous  membrane  at  the  vesical  neck  and  from  the  upper 


Fig.  1329. — Lnnsitndinal  section  of  enlar<red  prostate  and  part  of  posterior  wall  of  blad- 
der, a.  Moderate  intra-uretiiral  jirojection  of  left  lateral  lobe.  h.  Knlarirenient  of 
the  posterior  part  of  the  left  lateral  lobe.     c.  Seminal  duct.     d.  Part  of  left  wall  of 

bladr  ~  

centic- 


posrerior  pan  oi  me  leiu  laieiai  luue.  r.  .^trmui.u  uu<.i.  n.  i<iiL  wi  nm  .. mx  <j.. 
Ider.  m.  Enlarj^ed  middle  lobe  projecting  upward  into  bladder,  causing  a  eres- 
tic-shaped  urethral  orifice  (may  be  enucleated).     (From  Alexander's  collection.) 


portion  of  the  prostatic  urethra;  during  this  part  of  the  operation  the 
mass  to  be  enucleated  may  be  seized  with  forceps  passed  into  the  perineal 
wound  and  drawn  down  into  the  periureum.      The  finger  in  the  bladder 


■^^l^Q  OPERATIVE   SURGERY. 

may  be  passed  into  the  urethra  during  this  procedure,  and  prevents  tear- 
ing- the  mucous  membrane.  Having  removed  the  obstructing  growth  from 
one  lateral  lobe,  a  similar  procedure  is  done  upon  the  other  side  if  neces- 
sary. When  a  so-called  middle-lobe  enlargement  exists,  this  can  be  re- 
moved by  pressing  it  down  from  above  into  the  cavity  formed  by  the 
removal  of  the  lateral  lobes,  when  it  can  be  easily  removed  in  the  same 
manner.  The  only  part  of  the  urethra  torn  is  that  in  front  of  the  opening 
of  the  seminal  ducts.  After  removal  of  all  the  obstructing  portions,  the 
wound  and  bladder  are  flushed  with  a  hot  saline  solution ;  haemorrhage  is 
controlled  by  pressure ;  a  large  catheter,  about  30  F.,  Avith  thick  walls,  is 
introduced  into  the  bladder  through  the  perineum  and  a  rubber  drainage 
tube  with  a  single  eye  near  the  end  is  inserted  into  the  bladder  through  the 
suprapubic  tube.  The  bladder  is  then  closed  about  this  tube  in  the  manner 
recommended  by  Gibson  (page  1126),  the  perineal  tube  is  retained  in  place 
by  tapes  fastened  to  a  waist  band,  and  the  bladder  is  drained  through  the 
perineal  tube  by  siphon.  The  after-treatment  consists  in  daily  washing  the 
bladder.  The  upper  tube  is  removed  on  the  fourth  day  and  the  lower  tube 
at  the  end  of  one  w^eek.  Both  wounds  have  usually  healed  by  the  end  of 
five  weeks.  The  advantages  we  have  claimed  for  this  method  are :  1,  the 
entire  obstructing  portions  of  the  prostate  are  thoroughly  removed  through 
a  perineal  opening  without  injury  to  the  mucous  membrane  of  the  bladder, 
or  of  the  prostatic  urethra  above  the  opening  of  the  seminal  duct ;  2,  haemor- 
rhage is  rarely  a  serious  complication ;  3,  the  most  efficient  and  thorough 
drainage  of  the  bladder  is  secured  ;  4,  the  time  required  by  practiced  hands 
to  perform  the  operation  is  comparatively  short ;  5,  the  best  conditions  are 
left  for  a  return  of  complete  voluntary  urination. 

"  llie  Dangers  of  the  Operation. — Dangers  of  the  operation  are  :  1,  sup- 
pression of  urine  in  those  cases  in  which  there  is  advanced  renal  disease ;  2, 
haemorrhage.  Haemorrhage  is  rarely  serious,  and  can  always  be  controlled 
by  packing  the  perineal  wound  with  gauze  about  the  drainage  tube ;  3,  injury 
to  the  rectum.  This  may  occur  at  the  time  that  the  obstructing  portions  of 
the  prostate  are  detached  from  the  anterior  portion  of  the  urethra.  It  is, 
however,  necessary  only  to  remember  this  danger  to  avoid  it. 

"  The  Results. — The  results  of  the  operation  in  our  hands  have  been 
good,  considering  the  very  bad  condition  of  most  of  the  patients  operated 
upon.  The  following  is  a  summary  of  the  writer's  cases :  31  cases,  3  deaths, 
1  due  to  sepsis;  1  due  to  uraemia;  1  due  to  sepsis  and  uramia.  One  partial 
success  :  the  patient  emptied  his  bladder  completely,  but  had,  at  last  reports, 
a  small  rectal  fistula,  resulting  from  a  tear  into  the  rectum  during  operation  ; 
27  successful  cases,  in  which  the  vesical  function  was  restored,  the  patients 
emptying  their  bladders  completely." 

Many  modifications  have  been  advised  and  practiced  with  the  idea  of 
avoiding  the  suprapubic  cystotomy  element  of  the  combined  method.  The 
knowledge  of  the  fact  that  Alexander  was  able  in  two  very  thin  subjects  to 
dispense  wnth  suprapubic  cystotomy  and  successfully  enucleate  the  prostate 
aided  by  pressure  with  the  hand  made  behind  the  symphysis,  prompted 
Sijms  to  advise   that  the  prostate  be  pressed  against  the  perineum  from 


Ol'KUATKJNS    OS    Till':    IKINAKV    I'.l.A  DDKi:.  1141 

witliiii  the  abdomen  by  the  hand  curried  through  an  incision  made  in  the 
meilian  line  just  above  the  vesical  fold  of  the  j»eriton*um.  The  liability 
to  infection  and  to  injury  of  the  bladder  from  undue  pressnre  and  from 
serious  involvement  of  the  organ  by  the  enucleating  jjrocess  are,  thougli 
snllieiently  ol)vious  to  invite  preventive  caution,  of  such  an  apparent  gravity 
in  other  than  skilled  use  as  to  expose  the  method  to  wise  practical  objec- 
tions. Syms  suggested  also  the  introduction  through  the  perineal  incision 
into  the  bladder  of  a  collapsed  soft-rubber  bag  to  which  is  attached  a  strong, 
thick  rubber  tube.  The  distention  of  the  bag  with  water,  followed  by 
gentle  downward  traction  ou  the  tube,  serves  to  draw  down  and  steady  the 
prostate  so  that  enucleation  may  be  practiced  through  the  perineal  incision. 
Johnson  made  a  small  opening  just  above  the  pubis  into  the  space  of 
Retzius  (e.  Fig.  13T8),  through  which  the  linger  was  introduced,  carried 
down  to  and  caused  to  press  upon  the  prostate  while  the  enucleation  was 
successfully  performed  through  the  perineal  incision.  It  is  evident  that 
this  plan  is  best  suited  to  small  and  thin  patients.  Mynter  reports  a  case 
of  enucleation  accomplished  with  comparative  ease  and  practical  success 
upon  a  large,  stout  patient  (two  hundred  and  forty  pounds)  in  the  following 
manner :  The  posterior  extremity  of  the  usual  longitudinal  incision  was 
extended  backward  in  a  curved  manner  so  as  to  correspond  to  the  anterior 
lialf  of  the  circumference  of  the  anus.  The  curved  Haps  were  reliected 
outward  and  the  prostate  exposed  to  view.  A  grooved  staff  was  then  intro- 
duced into  the  uretlira  to  afford  a  better  outline  of  the  canal  in  the  prostate. 
A  median  incision  was  made  into  the  posterior  part  of  the  prostate  without 
opening  the  urethra,  through  which  wound  the  enlarged  lateral  and  middle 
lobes  were  easily  enucleated  with  the  finger  while  manual  pressure  from  above 
behind  the  symphysis  pubis  was  made  on  the  prostate.  In  this  instance  the 
pronounced  bordei's  of  the  grooved  staff  contributed  to  rupture  of  the  urethra 
during  enucleation.  Venous  oozing  from  the  prostate  characterized  this 
case  for  some  hours  after  ojieration.  Fuller  exposes  the  gland  with  scissors, 
inserts  the  finger  into  the  incision,  and  enucleates  the  growth  while  firm 
upward  pressure  is  made  on  the  periua-um.  Suprapubic  and  perineal  drain- 
age is  then  established.  Guiteras  makes  counterpressure  on  the  prostate 
during  intravesical  enucleation  by  means  of  two  fingers  introduced  into  the 
rectum. 

The  General  Remarlcs. — Complete  and  final  cure  from  any  method  of 
operation  should  not  be  too  confidently  expected,  but  much  relief  and  even 
practical  cure  happens  in  many  cases.  It  is  quite  evident  that  the  ideal 
method  of  practice  is  yet  to  be  established,  also  that  the  many  important 
novel  suggestions  of  practical  utility  frequently  presented  by  thoughtful, 
skillful  operators  may  be  regarded  as  an  earnest  of  an  early  and  final  success. 
Enough,  however,  is  already  known  to  enable  one  to  exercise  wise  discretion 
in  the  adoption  of  the  method  to  fit  the  case. 

The  Resnlts. — Treves  quotes  Belfield  as  follows:  "  Dr.  Belfield  gives  the 
mortality  of  prostatectomy  as  13  per  cent,  that  of  the  perineal  operation  as 
9  per  cent,  and  of  the  suprapubic  as  IG  jjer  cent.  lie  gives  the  following 
table : 


1142 


OPERATIVE   SURGERY. 


Restoration  of  Voluntary 
Urination. 

Cases. 

Successes. 

Failures. 

Deaths. 

By  perineal  incision 

By  suprapubic  incision  .  . 
By  combined  incisions .  . . 

41 

88 

4 

17 

29 

3 

7 

12 

0 

4 

12 

1 

133 

40 

19 

17 

"  The  discrepancy  in  the  totals  of  the  second  and  third  columns  depends 
upon  the  fact  that,  in  estimating  the  result  of  the  operation,  the  author  has 
omitted  all  cases  in  which  the  history  after  operation  is  imperfect." 

Besnos,  in  22  cases  of  his  own,  reports  2  deaths  (with  aggravated  symp- 
toms), 4  not  improved,  and  15  improved  and  cured. 

Castration,  operations  on  the  vasa  deferentia,  and  ligature  of  the  iliac 
arteries  are  each  practiced  to  a  greater  or  lesser  extent  for  the  cure  and 
relief  of  prostate  hypertrophy.  The  technique  of  these  various  oi3erations 
can  be  found  under  the  proper  headings,  and  the  results  only  will  be  given 
at  this  time.  In  1893*  White  formally  announced  to  the  profession  his 
belief  in  castration  for  relief  from  the  afflictions  of  prostatic  hypertrophy. 
Since  that  time  many  operations  of  this  nature  have  been  done,  some  of 
doubtful  result,  others  premature,  and  many  ill-judged,  as  will  necessarily 
happen  in  novel  proposals.  However,  sufficiently  trustworthy  results  are 
now  before  us  to  establish  the  fact  that  castration  should  be  regarded  as 
one  of  the  proper  methods  of  treatment  in  selected  cases.  The  sentimental 
objection  will  no  doubt  lead  to  delay  that  will  lessen  the  benefit  that  other- 
wise might  be  experienced.  There  is  not  yet  sufficient  ground  on  which 
to  rest  a  belief  that  the  removal  of  one  testicle  exercises  a  beneficial  influence. 
However,  since  isolated  cases  suggest  the  possibility  of  benefit,  one  may  be 
removed,  succeeded  by  the  other  if  desirable. 

Femoich  regards  double  castration  of  value  in  the  following  conditions : 
1,  in  reducing  bulky  overgrowth  of  the  lateral  lobes  of  the  prostate ;  it  may 
be  found  that  the  small,  tough,  fibrous  median  or  lateral  vesical  outgrowths 
will  be  better  removed  by  suprapubic  prostatectomy ;  2,  in  controlling  the 
distress  and  danger  of  an  inflamed,  senile,  enlarged  prostate ;  3,  in  lessening 
the  frequency  or  difficulty  of  introducing  the  catheter  in  advanced  or  con- 
firmed catheter  life ;  4,  in  avoiding  the  mechanical  difficulty  of  crushing  a 
post-prostatic  or  a  post-trigonal  stone  by  leveling  the  base  of  the  bladder, 
thus  rendering  the  operation  of  litholapaxy  feasible  in  a  condition  in  which 
before  it  was  impracticable ;  5,  in  reducing  chronic  cystitis  and  recurrent 
phosphatic  calculus  in  cases  of  confirmed  catheter  life. 

'The  Results. — The  death  rate  of  operation  is  reported,  5  to  10  per  cent 
in  selected  cases;  permanently  improved,  Tl  per  cent;  return  of  bladder 
contractility,  66  per  cent ;  cystitis  relieved,  52  per  cent.  Xo  doubt  a  more 
extended  experience  will  serve  to  place  this  plan  in  its  proper  station. 

Vasectomy  (Albarran). — The  exposure  of  the  cord  as  it  escapes  from  tlie 
external  ring,  and  in  its  course  to  the  testis,  followed  by  ligature  or  section 


*  Transactions  of  the  American  Surgical  Association,  1893. 


OPERATIONS   ON    TlIK    IKIiNAKV    15I.A  l)l)i:i;.  II43 

of  the  vas,  or  division  of  the  nerves,  or  ligature  of  tiie  arteries  of  the  testicle, 
is  quite  an  easy  matter  (page  l;:i2G).  The  vas  deferens  is  recognized  by  its 
pearly,  lirni  structure.  It  is  located  behind  the  testicle  and  posteriorly  in 
the  spermatic  conl. 

The  lU'sults. — The  reported  death  rate  of  operation  is  quite  as  miu-h  as 
in  castration  ;  })ermanently  improved,  59  to  82  per  cent.  In  mild  cases  and 
in  tiiose  who  refuse  castration  vasectomy  may  be  employed.  l>ut,  since  the 
danger  is  quite  as  great  and  the  outcome  not  so  good,  castration  should  be 
given  the  prefereiu'e  as  a  surgical  expedient. 

Ligature  of  the  internal  iliac  arteries  {liicr)  has  been  practiced  by  ^[eyer 
and  others,  but  not  with  that  degree  of  success  that  justifies  the  substitution 
of  this  measure  for  cither  of  the  preceding  plans  of  treatment. 

The  Galvano-cautery  Method  {Bottini). — Bottini  introduced  to  the  pro- 
fession the  application  of  galvano-cautery  for  treatment  of  prostatic  obstruc- 
tion. 

The  Operation. — Thoroughly  clefinse  the  bladder  and  urethra,  and  em- 
ploy general  or  local  anaesthesia ;  inti'oduce  into  the  bladder  six  or  eight 
ounces  of  sterilized  water;  carry  cautiously  into  the  bladder  the  electrode; 
turn  downward  the  beak  of  the  instrument,  and  withdraw  it  until  the  beak 
is  arrested  by  the  base  of  the  enlarged  prostate ;  introduce  into  the  rectum 
the  index  linger  and  note  that  the  beak  is  properly  located ;  turn  on  the  cur- 
rent (45  amperes)  and  manipulate  the  wheel  at  the  end  of  the  instrument  so 
as  to  burn  a  furrow  through  the  prostate ;  arrest  the  current,  change  the 
direction  of  the  beak  to  the  right  or  left,  at  about  a  right  angle  with  the 
primary  application,  and  repeat  the  process ;  treat  the  opposite  lateral  lobe 
in  a  similar  manner.  During  the  time  of  action  of  the  electrode,  cold  water 
is  caused  to  flow  from  a  fountain  syringe  freely  through  the  catheter  to  pre- 
vent it  from  becoming  overheated.  The  instrument  is  pushed  into  the  blad- 
der and  allowed  to  cool  before  it  is  withdrawn. 

TJie  Eemarks. — Afterward  a  catheter  is  tied  in  the  bladder  for  a  few 
days,  and  the  patient  given  Avater  freely  and  submitted  to  general  and  local 
bladder  medication.  Only  the  most  approved  apparatus  should  be  employed 
for  the  purpose,  and  the  measure  of  the  current  should  be  ascertained  and 
kept  in  view  during  the  proceeding.  The  bladder  is  washed  freely  with 
boric-acid  solution  sufficiently  often  to  remove  offending  substances.  Care 
should  be  employed  in  the  introduction  of  the  electrode,  as  the  beaked  end 
may  catch  in  the  triangular  ligament  (Figs.  1378  and  13T9),  especially  with 
the  employment  of  local  anaesthesia. 

The  Eesidts. — Bottini  reports  67  per  cent  of  cures,  15  per  cent  unim- 
proved, 15.85  per  cent  no  report,  and  2.6  died,  in  a  series  of  77.  Surely  if 
these  results  are  accepted  as  conclusive  evidence  of  the  resources  of  the 
method,  it  must  be  given  its  proper  place  in  the  list  of  means  of  relief. 

Clark.,  Meyer,  Mcdoican,  Guiteras,  and  many  others  have  contributed 
their  confidence  in  the  method,  as  emphasized  by  their  operative  efforts.  How- 
ever, the  element  of  uncertainty  that  attends  operations  conducted  in  the 
dark,  together  with  its  novelty,  prompts  us  to  advise  a  suspension  of  judg- 
ment while  abiding  the  outcome  of  still  further  demonstration. 


1144 


OPERATIVE  SURGERY. 


Prostatic  Abscess. — Prostatic  abscess  is  preceded  usually  by  an  acute 
parenchyuiatous  inflammation  of  tbe  prostate  body.  The  common  directions 
of  pointing  of  the  abscess  are  toward  the  urethra,  rectum,  and  the  perinajum. 
Infrequently  they  point  in  the  inguinal  or  the  obturator  region;  sometimes 
in  the  sjiace  of  Retzius  and  the  peritoneal  cavity.  Prostatic  abscess  should 
be  opened  and  drained  as  soon  as  the  diagnosis  is  made,  in  order  to  forestall 
the  escape  of  the  pus  into  either  of  the  places  already  indicated. 

lite  Operation  (Dittel  and  Zuckerkandl). — Evacuate  and  cleanse  the 
rectum  ;  shave  and  scrub  the  perinseum;  place  the  patient  in  the  position  for 
perineal  lithotomy;  introduce  a  large  sound  into  the  bladder  and  give  it  in 
charge  of  an  assistant ;  pass  the  left  index  finger  into  the  rectum ;  begin  a 
convex  incision  at  the  right  between  the  tuber  ischii  and  the  rectum,  and 


■?^x  ^  .^-"^li 


Fig.  1330. — Curved  transverse  incision  of  perinjeinn  for  access  to  prostate,  seminal  vesicles, 
etc.  Curve  should  conforai  to  outline  of  incision  in  Fig.  1331  in  latter  instances  of 
access. 


carry  it  forward  to  the  posterior  limit  of  the  bulbous  urethra,  thence  sym- 
metrically backward  to  a  point  at  the  opposite  side  corresponding  to  that  of 
starting  (Fig.  1330) ;  divide  the  superficial  fascia  of  the  perineum  along  the 


OrERATlONS   UN    TlIK    L'KINARV    BLADDER. 


1145 


line  of  incision  and  enter  the  isehio-rectal  fossa  at  either  side  (Fig.  1331); 
separate  the  llap  anil  turn  it  backward  as  far  as  the  lower  surface  of  the 
sphincter  aiii  muscle;  push  at  the  same  time  the  hiemorrhoidal  vessels  and 


Fig.  1331. — Superficial  surgical  anatomy  of  perinteuin.  o.  Superficial  perineal  vessels 
and  nerves,  b.  Erector  penis  muscle,  c.  Accelerator  urinal  muscle,  d.  Triangular 
ligament,     e.  Transversus  perineii  muscle.    /.  Levator  ani  muscle. 

nerves  backAvard  and  the  superficial  perineal  vessels  and  nerves  and  the 
bulb  forward ;  divide  the  connecting  fibers  between  the  external  sphincter 
ani  and  the  accelerator  nrinne  muscles  transversely,  and  draw  the  bulbous 
nrethra  forward ;  sever  the  anterior  layer  of  the  deep  perineal  fascia  from 
the  fascia  in  front  of  the  levator  ani  at  the  bulb  (anal  fascia),  and  draw 
the  muscle,  the  fascia,  and  the  lower  end  of  the  rectum  backward,  thus 
exposing  the  deep  layer  of  the  triangular  ligament  at  that  situation,  the 
compressor  urethn^  muscle,  and  Cowper's  glands;  dissect  upward  through 
the  fascia  without  cutting ;  sever  the  transverse  muscular  fiber  layer  that 
connects  the  anterior  bundles  of  the  levator  ani  muscle  at  the  anterior  sur- 
face of  the  rectum ;  separate  and  draw  aside  the  fibers  of  the  levator  ani  so 
as  to  bring  into  view  the  posterior  surface  of  the  prostate  and  the  seminal 
vesicles  higher  up  (Fig.  1332) ;  open  through  the  sheath  of  the  prostate  into 
the  abscess  cavity  carefully ;  evacuate,  wash  out  the  abscess,  and  drain  with 


1146 


OPERATIVE  SURGERY. 


a  small  tube  or  gauze  wick ;  close  the  external  wound  with  silkworm  gut, 
except  at  the  center  of  the  perinteum,  which  is  left  open  for  drainage  pur- 
poses. The  abscess  can  be  opened  satisfactorily  in  thin  subjects  by  a  median 
perineal  incision  made  behind  the  urethra  into  the  sheath  of  the  prostate. 

After  the  detection  of  pus  by  the  needle  or  by  palpation,  introduce  the 
left  forefinger  into  the  rectum  and  locate  the  fluctuating  point;  failing  in 
this,  place  the  end  of  the  finger  at  the  apex  of  the  prostate.      Introduce 


Fiu.  1332. — Deep  siirgieiil  anatomy  of  perinaHiin.  a.  Levator  ani  inusele.  b.  Internal 
pudic  nerve,  c.  Internal  pudic  artery,  d.  Transversus  perinei  muscle,  e.  Fibers  of 
compressor  uretliral  muscle.  /.  Prostate  body.  g.  Yas  deferens.  //.  Yesicula  semi- 
nalis.     L  Rectum,    j.  Bladder. 

(without  removing  the  finger)  with  the  cutting  edge  upward,  a  long,  straight, 
narrow  bistoury  at  the  median  line  of  the  perinaeum,  three  quarters  of  an 
inch  in  front  of  the  anus,  and  thrust  it  upward  to  the  abscess,  guided  by 
the  fingers  in  the  rectum ;  enlarge  the  incision  upward  sufficiently,  on  with- 
drawal of  the  knife,  to  afford  free  exit  for  pus ;  explore  the  cavity  with  an 
aseptic  finger,  breaking  down  abscess  partitions  when  found  ;  irrigate  the 
wound  with  a  hot  saline  solution,  and  arrest  profuse  deep  ha3morrhage  by 
packing. 


OPERATIONS   OX    TlllO    Li:L\Ai:V    liLADDEli.  1  [4.7 

111  eitluT  iiistimce  tlic  tube  sliould  bo  roinoved  ufter  a  few  days  and  gauze 
drainage  only  employed,  allowing  union  by  granulation. 

'I'he  lii'inarks. — If  pus  be  located  with  a  needle,  let  it  remain  as  a  guide 
to  puncture  of  the  abscess.  The  depth  of  the  pus  from  the  surface  will 
de})end  on  the  amount  and  extent  of  the  sup})uration,  and  the  thickness 
of  the  perinivuin.  A  de])th  of  an  inch  or  two  at  least  may  be  expected. 
Avoid  perforating  the  rectum  or  urethra  in  making  the  incision.  Abscesses 
ought  not  to  be  opened  into  the  rectum  unless  only  the  mucous  membrane 
be  interposed,  then  dilatation  of  the  spliincter  should  follow  at  once.  If 
the  abscess  have  opened  into  the  urethra,  perineal  section  should  be  per- 
formed, prostatic  urethra  dilated,  and  the  bladder  drained  for  ten  or  twelve 
days,  or  until  the  abscess  cavity  is  healed.  The  cavity  of  Retzius  (Fig.  1378) 
can  be  drained  through  the  perineal  opening  with  gauze  or  small  rubber 
tubes.  Improperly  drained  prostatic  abscess  is  complicated  not  infrequently 
with  fatal  phlebitis.  Prostatic  abscess  sometimes  opens  into  the  ischio-rectal 
fossa  (Fig.  1198),  and  is  then  difficult  to  heal,  because  of  the  numerous 
sinuses  that  complicate  it. 

The  Results. — Wide-apart  conclusions  are  reported  as  to  the  rate  of 
mortality — from  3  to  30  per  cent  are  given.  In  our  opinion  the  former 
estimate  is  the  more  correct  of  the  two.  About  40  per  cent  of  the  deaths 
are  due  to  prostatic  phlebitis — a  figure  which  may  be  regarded  as  a  low 
estimate,  indeed,  for  such  a  disease  and  its  sequels. 

The  seminal  vesicles  and  vasa  deferentia  can  be  reached  through  the  con- 
vex incision  (Fig.  1331),  but  with  some  difficulty  because  of  its  depth.  Rydy- 
giefs  osteoplastic  flap  in  proctotomy  (Fig.  Itib)  affords  easy  access,  and  free 
view  on  pushing  aside  the  rectum  and  partially  distending  the  bladder.  Dittel, 
after  passing  a  catheter  and  stuffing  the  rectum  with  gauze  having  a  string 
attachment,  placed  the  patient  in  the  same  position  as  for  operation  on  the 
prostate,  and  exposed  tlie  seminal  vesicles  through  a  like  incision  (Fig.  1326). 
Roux  attained  the  purpose  well  through  a  straight  four-inch  incision  made 
an  inch  to  the  left  of  the  median  line  of  the  perinaeum. 

Extroversion  of  the  Bladder.— In  extroversion  of  the  bladder  the  ante- 
rior wall  of  the  bladder  and  abdominal  parietes  are  absent,  while  the  poste- 
rior and  inferior  portion  of  the  bladder  protrudes  through  the  opening  in 
the  abdominal  wall  on  account  of  the  pressure  of  the  viscera  behind  it. 
Various  measures  have  been  attempted  to  establish  a  more  feasible  channel 
for  the  escape  of  urine,  none  of  which,  however,  have  afforded  any  practical 
benefit.  Simon  made  an  attempt  to  connect  the  ureters  with  the  rectum, 
but  with  no  practical  success.  Floyd  and  Johnson  iittempted  to  establish  a 
fistulous  communication  between  the  bladder  and  rectum  by  means  of  setons, 
but  the  patient  died  shortly  after  from  peritonitis.  Sonnenbury  extirpated 
the  bladder  (page  1156),  nnited  the  ureters  with  the  dorsal  groove  of  the 
penis,  and  closed  the  abdominal  wound  with  flaps ;  the  outcome  was  more 
of  a  surgical  than  a  practical  triumph.  The  methods  of  autoplasty  are  the 
most  rational,  and  have  in  many  instances  afforded  substantial  relief. 

The  operative  treatment  may  be  begun  as  early  as  four  years  of  age, 
the  sooner,  within  the  reasoning  limits  of  the  patient,  the  better,  as  the 


1148 


OPERATIVE  SURGERY. 


time  employed  in  the  cure  may  exceed  u  year  or  two.  The  patient's  phys- 
ical condition  should  be  good,  and  the  parts  should  not  be  disturbed  by 
emotional  causes.  All  evidences  of  local  irritation  should  be  subdued  and 
irritating  influences  removed  or  ameliorated.  The  practice  of  the  late  Grcig 
Smitli  bearing  on  a  case  of  this  kind  is  very  important,  lie  kept  the  patient 
on  the  back  for  fourteen  days,  hoping  to  diminish  the  size  of  the  tumor  by 
removal  of  the  weight  of  abdominal  contents.  In  order  to  exclude  atmos- 
pheric or  other  sources  of  irritation,  and  limit  the  deposition  of  phosphates 
by  the  prevention  of  evaporation,  he  covered  the  mucous  membrane  of  the 
deformity  with  oiled  silk  coated  with  dextrin  and  overlapped  with  a  double 
layer  of  boric  lint.  Bland  and  demulcent  drinks  were  freely  given.  He 
found  that  "  under  this  treatment  the  surface  of  the  extroverted  mucous 
membrane  soon  became  less  red  and  angry  looking,  and  latterly,  over  its 
upper  half,  as  low  down  as  the  orifice  of  the  ureters,  it  became  covered  with 
true  epidermis  almost  as  white  as  that  of  the  surrounding  skin.  The  muco- 
purulent discharges  diminished  considerably  in  amount,  and  the  excavations 
in  the  contiguous  skin  entirely  disappeared."  The  presence  of  hair  on  the 
reversed  flaps  provokes  the  dejoosit  of  phosphates,  especially  in  the  older  pa- 
tients. Therefore,  the  capil- 
lary growth  should  be  de- 
stroyed with  nitric  acid  or 
"M  electricity  before  the  utiliza- 

1  tion  of  the   surface.     IIow- 

j  ever,  in  very  young  subjects 

I  depilatation   is   not   needed, 

I  as     the    perversion    of    use 

j  seems  to  prevent  the  capil- 

i  lary  growth. 

\  Maury's  Method.— Make 

''.,„  a  curvilinear  incision  on  each 

\  side  with  the  convexity  up- 

i         ward,   extending    from    the 
1       outer  third  of  Poupart's  liga- 
\      ment  downward  and  inward 
\     below   the    scrotum    to   the 
perinfeum,   at    which    point 
they    become    joined    by    a 

Fig.  13:J3.— Miuu-y's  operation  for  extroversion  of  blad-  ^hort  transverse  incision  (J, 
der.  a'.  Reflected  perineal  flap,  h' .  Denuded  Fig.  1333).  This  flap  is  dis- 
surface  a,  &,  c.  Jejunostomy,  Albert's  method  sected  upward  over  the  scro- 
(page  7bb).  ^ 

tuni  to  the  root  of  the  penis, 

which  is  then  slipped  through  a  valvelikc  incision  made  at  the  base  of 
the  flap,  thus  permitting  the  urine  to  escape  without  coming  in  contact 
with  the  raw  surfaces  above.  A  second  or  abdominal  flap  is  now  formed  by 
carrying  a  transverse  incision  across  the  abdomen  below  the  umbilicus  and  a 
curvilinear  one  around  the  defect,  as  in  Bigelow's  operation  {a,  a,  a.  Fig. 
1334).     A  short  circular  flap  is  then  formed  by  dissection  of  the  borders  of 


OI'KKATIONS   ON    'I'lll';    lin.NAKV    I'.I.A DDKK. 


1140 


the  defect  for  al)out  ;iii  inch.  The  lower  thip  ( Fi<,^  l."):];),  ^/'),  is  tlien  turned 
upwiird  to  bring  its  eut;ineoiis  surface  in  conttict  with  the  mucous  surface  of 
the  bhidder.  The  cuticle  around  the  borders  is  removed,  so  that  the  borders 
can  be  placed  in  contact  and  united  with  freshened  surfaces.  Tiie  borders 
of  the  lower  Hap  are  fashioned  and  beveled  so  as  to  slip  under  the  circular 


Fig.  1334. — Bigelow's  operation  for  extrover-  Fig.  1335. — Bigelow's  operation  for  extro- 

sion  of  bladder,     a,  a,  a.   Flap-dissected  version  of  bladder  completed,     a,  a,  a. 

borders,      b,  b.  Flaps  from  inguinal  re-  Borders  of  incisions  united,    b,  b.  In- 

gion.  guinal  flaps  in  place. 

flap  at  the  border  of  the  defect,  to  which  it  is  united  by  catgut  or  quilled 
sutures.  This  method  offers  good  results  in  operations  upon  males,  Bige- 
low  dissected  off  the  mucous  membrane  of  the  exposed  bladder  down  to  a 
line  with  the  ureters  (Fig.  1334),  constructed  lateral  flaps  from  each  inguinal 
region,  united  them  in  the  median  line  and  above  (Fig.  1335),  and  thereby 
secured  a  perfect  result.  Skin  grafting  (page  513)  can  be  employed  in  the 
healing  of  surfaces  denuded  for  the  purposes  of  repair. 

Wood's  Method  (Fig.  133G). — Wood's  method  can  be  employed  in  both 
sexes,  but  is  better  adapted  to  the  female.  It  consists  in  making  a  central 
or  umbilical  flap  («),  after  which  a  lateral  flap  is  made  from  each  groin  (J,  c), 
and  carried  inward  over  the  previously  everted  central  one  and  united  in  the 
median  line  to  each  other. 

The  Operation. — The  central  flap  {a)  is  measured  upward  by  a  line 
extending  at  either  side  of  the  bladder  from  a  point  opposite  the  root  of  the 
penis  to  as  far  above  the  bla<lder  as  from  the  root  of  the  penis  to  the  upper 
margin  of  the  bladder,  and  joining  each  other  across  the  median  line  of  the 
abdomen  in  a  curved  manner  (Fig.  1336).  The  two  lateral  flaps  (J,  c)  are 
made  having  rounded  external  borders,  with  their  attachments  downward 
and  inward,  corresponding  to  the  base  of  the  scrotum  and  large  enough, 
■when  properly  detached  and  turned  inward,  to  meet  in  the  median  line 


1150 


OPERATIVE  SURGERY. 


their  entire  length.  Their  upper  limits  correspond  internal!}'  to  the  centers 
of  the  vertical  incisions.  Tiie  incision,  completing  the  inner  border  of  each 
flap,  is  carried  from  the  lower  end  of  the  vertical  incision  already  made 
along  the  side  of  the  urethral  groove  for  half  its  length.  After  proper  sep- 
aration of  the  flaps  the  central  or  umbilical  flap  is  turned  downward  and 
stitched  at  either  side  to  the  cut  edges  of  the  root  of  the  penis.  The  lateral 
flaps  are  carried  inward  over  the  umbilical  flap,  thus  apposing  the  raw  sur- 
faces of  the  respective  flaps  to  each  other.  The  flaps,  and  the  borders  of  the 
gaps  resulting  from  their  displacements,  are  united  as  indicated  in  the  illus- 
tration (Fig.  1337),  leaving  the  unclosed  spaces  to  heal  by  granuhition.  The 
root  of  the  penis  should  be  closely  embraced  by  the  lateral  flaps  to  prevent 
subsequent  weakness  and  protrusion  at  this  point.  The  integrity  of  the 
external  pudic  vessels  will  add  much  to  the  vitality   of  the  lateral  flaps. 


1^ 


Fig.  1336. — Wood's  operation  for  extrover-  Fig.  1337. — Wood's  operation  for  extrover- 
sion of  bladder,  a.  Central  flap,  h,  c.  sion  of  bladder,  a.  Upper  flap  raw  sur- 
Lateral  flaps.  face,      b,  c.  Lateral  flaps,     d.  Prostate 

body.     e.  Penis. 

Aseptic  precautions  and  careful  handling  of  the  flaps  are  important  de- 
siderata. 

The  Comments. — The  flaps  should  be  made  of  as  nearly  nnifonn  thick- 
ness as  possible  and  not  too  thin,  as  then  they  will  slough.  At  the  upper 
margin  of  the  bladder  the  tissues  are  so  thin  that  the  peritonaeum  may  be 
cut  unless  care  be  taken.     Harelip  sutures  need  not  necessarily  be  employed. 

Modifications  of  WoocVs  Operation. — Robson  modified  Wood's  operation 
in  a  case  of  his  own  in  the  following  manner :  "  A  large  square  flap  was  taken 
from  the  abdominal  wall  above  the  umbilicus  and  turned  downward  so 
that  the  cutaneous  surface  came  in  contact  with  the  exj)osed  vesical  mucous 
membrane  (Fig.  1338).  Pyriform  flaps,  one  on  each  side,  were  taken  from 
the  lateral  aspects  of  the  abdomen  and  twisted  inward  on  their  attachments, 


opki:ati()Ns  ox  tiiI':  ^I!I^^\I{^•  |{|.aI)1)i:k. 


1151 


so  that  their  niw  surfaces  came  in  contact  with  the  raw  surface  of  the  lirst- 
mentionetl  s(juare  Ihip.     Wiieii  secured  in  position  the  fhip  entirely  covered 


v-^-^:S[:^-v^. 


#  i 

Fig,  1338.— Robson's  modification  of  Wood's    Fig.  1339.— Robson's  modification  of  Wood'.s 
operation.      Foniiation   of   the   square  operation.    Flaps  placed  in  position  and 

and  pyrifonn  flaps.  borders  secured. 

the  vesical  surface.     The  edges  of   the  exposed  surfaces  on  the  abdomen 
were  drawn  together  and  secured  by  harelip  j^ius  and  sutures  "  (Fig.  1339). 


Fig.  1340.— Robson's  modification  of  Wood's    Fig.  1341.— Robson's  modification  of  Wood's 
operation.    Secondary  operation  to  rem-  operation.     Results  of  secondary  opera- 

edy  effects  of  retraction.  tion. 

The  retraction  incident  to  healing  brougiit  into  view  a  part  of   the  lower 
vesical  surface.     "  To  remedy  this  defect  the  prominent  folds  of  the  integu- 


1152  OPERATIVE   SURGERY. 

inent  forming  the  labia  majora  were  incised  for  three  inches  vertically,  and 
from  the  upper  ends  of  these  cuts  incisions  were  carried  outward  so  as  to 
allow  two  triangular  flaps  of  skin  to  be  carried  upward  (Fig.  1340).  The 
square  flap  of  skin  was  loosened  at  its  attachment  to  the  pyriform  flaps,  and 
turned  downward  so  that  the  cutaneous  surface  again  covered  the  bladder 
mucous  membrane.  The  newly  made  groin  flaps  were  approximated  toward 
the  middle  line  covering  the  raw  surface,  and  secured  in  apposition  for  an 
inch  and  a  half,  while  the  upper  margins  were  sutured  to  the  newly  refreshed 
lower  margins  of  the  pyriform  flaps  of  the  Wood  operation  "  (Fig.  1341). 

Greig  Smith  formed  the  flaps  a  little  larger  than  Wood  did,  and  shaped 
the  umbilical  one  to  conform  to  the  shape  of  the  wooden  portion  of  an  ordi- 
nary bellows,  the  handle  to  which  was  located  above  and  in  the  median  line, 
and  when  turned  down  and  united  to  tissues  raised  from  the  penis  and  scro- 
tum repaired  the  defective  urethra.  Quilled  sutures  were  employed  to  unite 
the  flaps. 

Thiersch's  Method. — Form  successively  two  lateral  flaps,  each  large  enough 
at  the  time  of  the  making  to  cover  the  entire  defect.  Begin  the  first  flap  by 
making  an  incision  from  the  upper  margin  of  the  defect  downward  along  its 
border  to  the  root  of  the  penis ;  begin  the  second  incision  the  width  of  the 
defect  to  the  outer  side  of  the  commencement  of  the  first,  and  carry  it  down 
parallel  with  the  first  to  Poupart's  ligament ;  detach  the  flap  between  the 
extremities,  leaving  the  latter  undivided ;  place  beneath  the  flap  tin  foil  for 
three  weeks  while  awaiting  granulation  ;  freshen  the  margin  of  the  lower 
portion  of  the  defect,  and  divide  the  flap  at  the  upper  end ;  turn  the  flap 
downward  so  as  to  cover  the  lower  part  of  the  defect  and  attach  it  to  the 
border  of  the  freshened  margin,  with  the  cutaneous  surface  upward  ;  freshen 
and  unite  the  end  of  the  flap  with  the  contiguous  freshened  border  of  the 
defect  after  the  former  is  securely  flxed  in  place.  After  the  first  flaj)  becomes 
firmly  attached,  make  the  second  of  the  same  dimensions  as  the  first  and 
correspondingly  located,  except  tliat  the  lower  limit  should  conform  to  the 
upper  border  of  the  first  one.  Treat  the  second  in  a  like  manner  as  the  first 
for  a  similar  time,  and  then  repair  the  upper  part  of  the  defect  with  the 
second  flap  in  the  same  manner  as  the  lower  part  was  repaired  by  the  first. 
After  a  secure  union  of  the  second  flap,  unite  with  each  other  the  contiguous 
borders  of  the  two,  and  also  the  upper  border  of  the  second,  with  the  fresh- 
ened upper  margin  of  the  deformity.  Eepair  the  urethral  deformity  at  a 
later  period. 

The  Remarks. — By  this  method  a  thin,  illy-nourished  umbilical  flap  and 
the  dangers  attending  its  construction  are  avoided,  and,  instead,  flaps  with 
established  vitality  are  employed. 

Modifications  of  Thiersdi's  Method. — When  it  is  impossible  to  close  en- 
tirely the  defect  by  Thiersch's  method,  Sego7id  recommends  that  a  smaller 
bladder  be  formed  in  the  following  manner  :  After  freshening  the  borders  of 
the  penile  furrow,  form  a  new  vesical  cavity  with  the  material  of  the  old  by 
an  extraperitoneal  dissection  downward  of  the  mucous  membrane  of  the 
bladder.  The  mucous  flap  is  turned  forward  and  downward  and  sutured  to 
the  freshened  penile  furrow.     Then  make  an  incision  through  the  prepuce. 


ol'EliATlUXS   UN    TllK    LliLNAKV    I'.LADUHK.  1153 

dissect  it  up,  dniw  it  over  tlie  glans  penis,  and  its  raw  surface,  with  that  of 
the  hiteral  al)(h)nuMal  Ihips,  is  emi)loyed  to  cover  the  mucous  membrane  lim- 
itin<j^  the  newly  formed  bhidder. 

TJie  Hc))utrks. — The  dilliculty  of  dissec^ting  away  the  mucous  membrane 
witliout  impairing  its  integrity,  or  implicating  the  peritoneal  cavity,  is  the 
chief  objection  to  this  operation.  Tlie  base;  of  tiie  mucous  ila{)  corresponds 
to  a  point  just  above  the  attachment  of  the  ureters  to  the  muscular  wall  of 
the  bladder. 

Ponifxon^  with  the  idea  of  avoiding  the  objectionable  features  just  stated, 
made  a  ilap  of  the  cxstrophied  bladder  by  carrying  an  incision  around  its  bor- 
der into  the  peritoneal  cavity.  This  flap  is  utilized  in  repair  the  same  as  the 
mucous  flap,  and  the  consequent  defect  in  the  abdominal  wall  is  closed  by 
direct  suture. 

Billroth,  in  1881,  expressed  himself  as  follows  :  "  At  first  I  used  to 
cover  over  the  extroversion  by  paring  and  uniting  the  abdominal  walls  after 
previously  detaching  the  bladder  from  them.  Then  for  a  while  I  tried 
making  two  lateral  pedunculated  flaps  from  the  abdominal  wall.  Now  I 
have  come  to  the  conclusion  that  the  best  method  is  to  dissect  up  two 
broad,  lateral,  doubly  pedunculated  flaps,  whose  narrow  parts  lie  above  and 
below.  After  ten  or  fourteen  days,  when  the  under  surface  is  granulating 
well,  I  unite  the  two  in  the  middle  line  without  cutting  through  the 
peduncles.  If  the  flaps  be  sufficiently  broad,  there  is  no  need  to  unite 
them  by  their  outer  edges  ;  these  latei'al  openings  close  spontaneously  in  from 
five  to  six  weeks.  The  bladder  is  thus  completely  covered  in,  but  an  open- 
ing should  be  left  at  the  umbilicus  through  which  the  urine  may  escape 
until  the  urethra  below  is  completely  formed ;  then  the  umbilical  opening  is 
closed,  and  it  heals  up  as  the  urine  escapes  below  by  the  newly  formed 
passage. 

"  The  flaps  must  be  made  very  broad — that  is  to  say,  in  an  adult  they 
should  be  at  least  six  centimetres  broad  in  the  middle  and  about  five  at  the 
upper  and  lower  parts ;  in  a  child,  of  course,  they  should  be  somewhat,  but 
still  not  so  very  much  smaller.  The  flaps  should  be  so  completely  detached 
as  to  overlap  each  other  for  about  half  their  width  ;  a  sheet  of  tin  foil  is  then 
laid  underneath  them  in  their  whole  length.  In  a  few  days  they  approxi- 
mate so  much  that  their  curved  shape  becomes  straight;  later  on,  notwith- 
standing a  certain  amount  of  rigidity,  they  will  readily  unite  in  the  middle 
line.  A  broad  surface  must  be  made  by  scraping  away  the  granulations  and 
the  superflcial  developing  e])iderinis  from  the  edges.  At  first  I  suspected 
that  this  median  cicatrix  might  possibly  give  way  as  the  bladder  was  pressed 
forward,  so  that  a  sort  of  vesical  hernia  might  form,  as  happens  occasionally 
under  similar  conditions  after  laparotomy.  I  have,  however,  a  case  under 
observation  which  was  cured  five  years  ago,  and  which  satisfactorily  proves 
that  such  a  fear  is  groundless. 

"  The  wounds  of  the  abdominal  wall,  after  the  formation  of  flaps  on  both 
sides,  are  of  rather  formidable  size.  The  hivmorrhage  can  easily  be  controlled. 
If  the  flaps  be  made  too  small,  a  strip  of  the  tissues  either  about  the  center 
or  above  it  is  apt  to  slough.     Such  an  occurrence  will  seriously  depreciate 


115J:  OPERATIVE   SUKGEliV. 

the  result.  A  further  disadvantage  of  making  the  flaps  too  small  is  that 
lateral  openings  will  be  left,  which  are  very  difticult  to  close." 

The  approximation  of  the  innominate  bones  as  an  element  of  cure  in  this 
deformity  has  attracted  considerable  notice  and  given  rise  to  many  ingenious 
conceptions  of  repair.  The  presence  of  a  gap  of  two  inches  or  more  between 
the  pubic  bones  in  exstrophy  of  the  bladder  has  long  been  recognized,  and 
the  possibility  of  closing  the  gap  considered.  Trendelenburg  regards  five 
years  of  age  as  the  best  period  for  operation,  and  practices  the  following  plan 
of  action  : 

Trendelenburg's  Method. — Xote  the  degree  of  separation  of  the  bones  in 
front,  and,  under  aseptic  precautions,  expose  and  divide  the  posterior  sacro- 
sciatic,  interosseous,  and  superior  ligaments  of  the  articulation  ;  freshen  and 
approximate  the  pubic  bones  so  as  to  close  the  gap  ;  close  and  drain  the  pos- 
terior wound,  and  apply  suitable  dressings  and  a  retention  band.  The  use 
of  transverse  traction  (Makins),  of  elastic  extension,  or  an  extension  by 
weights  applied  to  each  of  the  crossed  ends  of  a  pelvic  band,  will  hold  the 
pubic  bones  in  contact.  It  is  hardly  necessary  to  say  that  defilement  of  the 
point  of  juncture  will  delay  union,  and  may  develop  unfortunate  inflamma- 
tory complications. 

The  Jiemarks. — This  operation  is  better  adapted  to  the  male  than  the 
female  sex,  owing  to  the  objectionable  narrowing  of  the  pelvis  in  the  latter 
sex.  The  anterior  iliac  spines  are  the  bony  points  for  estimating  the  degree 
of  approximation,  and  although  easy  closure  of  the  vesical  defect  is  gained, 
an  absolute  value  can  not  yet  be  placed  on  the  operation. 

Konig  and  Kilster  substituted  for  the  sacro-iliac  separation  osteotomy  of 
the  pelvic  ring.  Passavant  proposed  closure  by  "  brisement  force  "  under 
anaesthesia.  Later  operators  regard  with  disfavor  all  of  these  attempts, 
because  of  the  primary  and  secondary  dangers  attending  them,  and  also  the 
fickleness  of  the  results.  The  various  transplantations  of  the  ureters  into 
the  rectum,  colon,  etc.,  with  the  view  of  relieving  the  patient  of  the  almost 
insufferable  nuisance  of  the  dribbling  urine,  are  considered  under  The  Sur- 
gery of  the  Ureters  (page  850  et  seq.).  Harrison  removed  one  kidney,  waited 
until  the  remaining  kidney  had  undergone  compensative  hypertrophy,  then 
transplanted  its  ureter  into  the  groin  and  collected  the  urine  with  a  suitable 
apparatus.  The  change  of  condition  brought  about  by  this  course  of  action 
afforded  the  patient  great  relief.  Repair  of  the  bladder  by  transference  to 
the  defect  of  intestine  has  been  practiced.  The  resection  of  the  trigone  so 
as  to  include  the  ureters,  and  its  transference  to  the  sigmoid  flexure  of  the 
colon  (Maydl),  followed  by  removal  of  the  bladder,  has  been  practiced  with 
remarkable  success.  Lewis  reports  seventeen  cases,  with  two  deaths,  one 
from  shock,  the  other  from  infection.  One  case  died  after  four  months 
from  pyonephrosis.  "  Urinary  continence  was  perfect  in  all  of  the  cases 
excepting  two."  The  urine  could  be  held  from  three  to  seven  hours,  and  in 
one  instance  the  entire  night.  The  tolerance  of  the  rectum  permitted  the 
urine  to  appear  with  or  without  fa?cal  matter,  as  the  condition  demanded. 

The  after-treatment  is  somewhat  perplexing,  because  of  the  necessity  to 
place  the  patient  and  protect  the  bed  so  as  to  jjrevent  objectionable  contami- 


opp]RA'ri(»Ns  ox  'nil-:  ikinauv  ni. adder. 


1155 


Tiatioii  of  citlicr  with  uiinury  disclmrgos.  Parker  phiced  his  patients  in  a 
wiiiiii  liip  liaili  ()(■  u  lioric-acid  solution  for  days  after  the  operation,  with 
comfort  uiul  ropurativi^  advantage  to  the  i)art.  Of  course,  tlie  bath  should 
be  maintained  at  a  comfortable  temperature,  and  frequently  changed  to 
preserve  the  recpiisite  degree  of  cleanliness.  Various  other  measures 
directed  to  a  like  ])ur{)ose  are  carried  into  elTect. 

TJic  Ufsults. — Control  of  the  bladder  while  in  an  erect  position  is  rarely 
secured  by  operation ;  this  need  is  ameliorated  by  the  use  of  the  rubber 
urinal.  However,  the  urine  is  often  under  quite  good  control  in  the  recum- 
bent posture.  The  death  rate  is  from  20  to  30  j)er  cent,  depending  upon 
the  character  of  the  efforts  employed. 

Poiisson  reports  52  cases,  of  which  4  died  from  the  operation ;  in  each 
of  these  Trendelenburg's  method,  had  been  practiced. 


\y 


Fig.  1342.— Mikulicz's  tampon  for  arrest  of  severe  ooziii":  in  deep  cavities.  Forceps 
grasping  apex  of  tampon  at  the  top  of  investing  fabric.  String  employed  in  removal 
tied  to  apex. 


Segond's  plan  appears  to  afford  excellent  results,  being  satisfactory  in  the 
10  cases  in  which  it  has  been  employed.  The  cause  of  death  often  arises 
from  ascending  infection  of  the  kidney,  provoked  by  an  excess  of  surgical 
attempt  and  a  lack  of  surgical  care. 

Extirpation  of  the  Bladder— /'^ /■//>//  and  complete  exfirpafion  of  the 
bladder  are  practiced  ;  the  former  (page  1122)  for  removal  of  limited  growths 
and  the  latter  for  the  extensive  ones  and  for  congenital  defects. 
79 


1156  OPERATIVE   SURGERY. 

Kiistcr  practiced  complete  removal  of  the  bladder  as  follows  :  After  thor- 
oughly shaving  and  cleansing  the  parts  the  patient  was  placed  in  the  Tren- 
delenburg posture,  the  bladder  exposed  above  the  brim  of  the  symphysis 
pubis,  the  brim  of  the  pelvis  chiseled  away,  the  fragments  remaining  attached 
to  the  muscular  insertions  above,  and  the  bladder  opened  for  the  purposes 
of  inspection.  After  thorough  observation  of  the  interior  the  opening  in 
the  organ  was  sewed  tight  and  the  viscus  itself  freed  by  blunt  dissection 
from  its  surroundings.  An  incision  was  made  in  the  median  line  of  the 
perinffium,  the  urethra  divided  transversely,  the  prostate  body  grasped  with 
the  fingers  and  liberated  by  blunt  dissection  with  scissors  and  fingers.  The 
incision  into  the  bladder  was  reopened  to  permit  of  the  localization  and 
exposure  of  the  ureters,  which  were  then  tied  with  silk  and  severed  obliquely 
from  in  front  backward  and  upward.  The  remaining  connections  of  the 
bladder  were  severed  with  scissors,  the  organ  was  removed,  and  the  ureters 
were  implanted  into  the  rectum.  After  thorough  cleansing  the  wound  was 
closed  by  restoring  and  wiring  in  place  the  fragments  of  bone  and  uniting 
the  soft  parts  in  the  usual  manner. 

The  Retnarks. — Openings  made  into  the  peritoneal  cavity  during  the 
operation  should  be  at  once  closed.  The  haemorrhage  should  be  thoroughly 
arrested  before  the  wound  is  finally  closed,  even  if  the  use  of  a  tampon  (Fig. 
1342)  be  required,  as  may  happen  if  malignant  involvement  be  unexpectedly 
extensive.  Thorough  drainage  should  be  secured.  If  the  ureters  be  im- 
planted in  the  bowel  and  the  bladder  left  m  situ,  the  organ  may  rapidly 
shrink  and  become  a  round,  hard,  and  indifferent  body.  The  substitution 
in  any  manner  for  the  bladder  of  an  intestinal  loop  does  not  afford  the  bright 
outlook  that  has  characterized  the  successful  efforts  of  Maydl  and  his  fol- 
lowers. 

STONE    IN   THE    BLADDER. 

Stone  in  the  bladder  is  quite  common,  and  usually  is  accompanied  by 
well-marked  and  characteristic  symptoms.  Sometimes,  however,  calculi  of 
inordinate  size  and  with  unusual  asperities  are  attended  by  only  trifling 
manifestations. 

The  Detection  of  Stone  in  the  Bladder. — When  it  is  suspected  that  a 
stone  may  be  in  the  bladder  the  proof  of  its  presence  is  sought  by  a  searcher, 
by  bimanual  palpation,  and  the  use  of  a  cystoscope.  The  lithotrite,  the 
evacuator,  and  the  ordinary  sound  can  be  used  for  the  purpose,  but  not  with 
the  technical  skill  and  surgical  justification  that  belong  to  the  use  of  tlie 
first  three  means  of  exploration.  There  are  various  patterns  of  searchers 
(Figs.  1343,  1344,  and  1345).  Tlie  one  devised  by  Thompson  is  most  com- 
monly employed.  It  can  be  used  for  the  double  purpose  of  regulating  the 
amount  of  water  in  the  bladder  by  injection  or  by  outflow,  thereby  better 
accommodating  the  bladder  walls  to  the  main  object  of  the  use  of  the  in- 
strument— sounding  for  stone. 

The  time  of  sounding  for  stone  should  be  when  the  patient  is  suffering 
the  least  from  the  bladder  difficulty.  If  the  patient  be  a  child  an  anaBSthetic 
should  be  given,  if  an  adult  only  when  he  is  extremely  restless  from  the 


OPKHATIONS   ON    TIIH    lUlNAin'    I'.I.A  DDKR. 


1157 


pain.  Two  or  throe  ounces  of  a  two-per-cent  solution  of  cocaiu  liavc  been 
employed  successfully  in  the  bladder  to  relieve  the  ]iain  and  irritation  of 
soundiuij.  The  urine  of  one  or  two  hours'  secretion  should  be  allowed  to 
collect  in  the  bladder,  or  its  equivalent,  four  or  five  ounces  of  warm  ster- 
ilized water,  should  be  injected  before  attempting  the  act.  Not  infrequently 
it  is  wise  to  distend  the  bladder  with  aseptic  lluid 
before  sounding,  so  that  the  characteristics  of  the 
stone  and  the  bladder  can  be  tiie  better  estimated  by 
allowing  the  lluid  to  slowly  escape  during  the  ex- 
plorative mani])ulations. 

TJte  Operation  of  Soimding. — Place 
the  patient  on  the  back  with  the  hips 
raised,  the  operator  standing  upon  the 
right  side.  Introduce  the  searcher  in 
substantially  the  same  manner  as  em- 
ployed in  the  introduction  of  a  catheter 
or  sound  (})age  1109);  push  the  instru- 
ment carefully  to  the  posterior  wall  of 
the  bladder,  with  the  beak  upward  ; 
withdraw  it  slightly  to  give  easy  play  to 
the  vesical  end,  and  then  carefully  turn 
the  beak  from  side  to  side  until  the 
lateral  walls  of  the  bladder  are  touched 
by  it.  This  is  done  by  rotating  the  in- 
strument on  its  long  axis  between  the 
thumb  and  finger.  Turn  the  beak 
downward  and  examine  the  base  of  the 
bladder.  In  this  manner  the  whole 
inner  surface  of  the  bladder  is  exam- 
ined, the  instrument  being  withdrawn 
each  time  a  sutticient  distance  to  ac- 
complish the  object  thoroughly.  As 
soon  as  the  beak  comes  in  contact  with 
the  neck  of  the  bladder  the  instrument 
may  be  withdrawn.  If  the  prostate 
be  enlarged,  the  handle  should  be  de- 
pressed and  the  beak  turned  toward  the  floor  of  the  bladder  and  rotated 
from  side  to  side  while  being  gradually  withdrawn.  This  manoeuvre  will 
be  quite  sure  to  detect  a  stone  if  it  be  lodged  behind  the  prostate. 

If  a  stone  be  not  detected,  it  is  better  to  make  a  second  and  even  a  third 
examination  before  positively  asserting  that  none  is  present.  Five  or  ten 
minutes  is  quite  sufficient  time  to  employ  at  a  sitting.  If  the  presence  of 
stone  be  detected,  the  number,  size,  and  the  probable  consistence  should  be 
determined.  The  presence  of  two  and  even  three  calculi  can  be  reasonably 
estimated  by  careful  manipulation  w'ith  the  searcher.  However,  this  knowl- 
edge is  best  gained  by  the  use  of  the  lithotrite.  If  a  stone  be  grasped  by 
this  instrument  the  presence  also  of  one  at  either  side  of  the  beak  can  be 


Fig. 1343. 

Thompson's 

searcher. 


Fig.  1344. 

Little's 

searcher. 


Fig.  1345. 
Gouley's 
searcher. 


1158 


OPERATIVE   SURGERY. 


determined  with  reasonable  certainty  by  the  alternating  "clicks"  attending 
the  turning  of  the  beak  from  side  to  side.  The  size  of  the  stone  can  be  esti- 
mated ap])roximately  with  a  searcher  by  noting  the  extent  of  the  area  of 
friction  and  distance  of  the  exposure  of  the  shaft  of  the  instrument  at  the 
meatus  when  the  beak  is  applied  alternately  to  the  anterior  and  posterior  sur- 
faces of  the  calculus.  The  dimensions  of  the  object  grasped  by  a  lithotrite 
can  be  accurately  determined.     The  distinctness  of  the  click  will  indicate 


Fig.  1346. — Andrew's  searcher,  with  a  tube  to  convey  the  sound  to  the  ear. 

the  hardness  of  the  stone  as  a  rule.  A  pasty  stone  will  give  a  soft,  low- 
pitched  sound  ;  the  reverse  will  follow  contact  with  a  hard  one.  A  hard 
stone  surrounded  with  organic  matter  may  be  mistaken  for  a  soft  one. 
After  the  searching  is  completed  apply  warmth  to  the  hypogastriuzn,  give 
an  anodyne  and  possibly  ten  grains  of  quinine,  and  keep  the  patient  quiet. 

The  Comments. — The  ability  to  detect  the  "click"  of  small  stones  and 
fragments  by  aid  of  the  searcher  is  greatly  enhanced  by  the  attachment  of 
the  so-called  "  lithophone."  This  attachment  can  be  extemporized  by  taking 
a  piece  of  rubber  tubing,  twenty-five  or  thirty  inches  in  length  with  an 
eighth  of  an  inch  caliber ;  double  one  end  upon  itself  and  place  it  against 
the  handle  of  the  searcher,  allowing  also  the  tubing  continuous  with  it  to  lie 
along  the  handle,  or  push  it  into  the  open  end  of  the  handle  of  the  searcher. 
The  other  extremity  is  then  placed  in  the  ear  directly,  or  connected  to  it  by 
the  medium  of  an  otoscope  (Fig.  134G).  The  ability  to  detect  fragments  of 
an  almost  infinitesimal  size  is  said  to  be  thus  attained  (Fig.  1347).  The  wash- 
ing process  of  litholapaxy  will  also  cause  the 
"  click,"  when  other  measures  have  failed. 

The  Fallacies. — The  fallacies  of  sounding 


Fig.  1347. 


-Billroth's  sounding-board  attached  to 
scarclier. 


are  quite  numerous,  as  a  stone  may  be  obscured 

more  or  less  by  mucous  membrane,  inspissated 

mucus,  or  blood,  and  when  pocketed  in  an  adventitious  place.     Calcareous 

incrustations   connected   with   the  wall   of  the   l)la(lder,  or  with   a  morbid 

growth,  are  sometimes  mistaken  for  calculi.     Finsilly,  the  instrument  may 

not  enter  the  bladder  at  all,  and  thus  completely  deceive  the  examiner. 

Bimanual  Palpation.— Bimanual  palpation  can  be  practiced  in  either  sex 
with  satisfactory  results  if  the  patient  is  not  of  an  unusual  muscular  or  adi- 


OPFRATTOXS   OX   TIIH    rinXAIIV    ULA  DDi:!?. 


1159 


pose  dovelopnioiit.  In  tlio  riiiilo  tlie  })iitit'nt  is  phu't'd  usually  on  tlio  ]>afk,  with 
tiie  thighs  lloxcd  tmd  the  shoulders  raised  so  us  to  relax  the  abdominal  wall. 
The  examiner  introduces  the  index  finger  of  tiie  right  hand  into  the  rectum 
of  the  patient,  and  presses  the  tips  of  the  fingt-rs  of  the  left  behind  the 
pubes  and  the  bladder.  Between  the  apposing  linger  tips  an  empty  bladder 
/•/ToSv  '■"'^'^  '^^  '^^  thoroughly  examined  as  to  detect  in  it  the  presence  of  a 
calculus  of  siiudl  size.  Any  undue  pain  or  mental  trepidation 
inciilent  to  the  act  can  be  relieved  by  general  or  local  aiuesthe- 


FiQ.  1348. — I.  Nitzc's  eystoscope.     IT.  Longitudinal  section  of  I.      a.  Shaft,     b.  Prism. 
c.  Incaiules^eent  light  which  is  fastened  into  tiie  small  compartment/. 

sia  if  the  importance  of  the  condition  justifies  the  use.  In  the  female  the 
manipulation  is  easier  and  even  more  conclusive,  on  account  of  the  absence 
of  the  prostate  and  the  intimate  relations  of  the  base  of  the  bladder  and 
vagina.  In  either  sex  the  rectum  should  be  thoroughly  evacuated  before 
the  examination  is  begun. 

The  Cystoscope. — The  use  of  the  eystoscope  is  often  advantageous  in  the 
determinaLion  of  morbid  conditions  of  the  kidney  or  the  cavity  of  the  bladder, 

c  "        i 


Fig.  1R49. — Loiter's  cystoscope.  T.  Longitudinal  section,  a.  .Metallic  compartinent  and 
electric  light,  b.  Depression  for  the  window,  d.  Mechanism  for  closing  the  current, 
n.  The  same  on  a  large  scale.  IIL  Klectro-endoscope  for  illumination  of  the  exter- 
nal auditory  meatus,  the  tt>sophagus.  and  the  urethra,  ri.  Obliquely  placed  cf>ncave 
mirror  which  reflects  the  rays  from  the  incandescent  light  in  the  tip  of  the  instru- 
ment into  the  opening  of  the  tube  at  c.  b.  Correcting  lens  for  persons  with  myopia 
and  hypermetropia. 

and  the  interpretation  of  the  functional  phonomena  of  these  organs  (Figs. 
1348  and  1349).     A  detailed  description  will  not  be  given  of  the  various 


1160  OPERATIVE   SURGERY. 

cystoscopes,  as  the  coutiuual  improvements  and  the  extending  scope  of  the 
usefulness  of  the  instruments  forbid  a  commendation  tliat  may  soon  be  of 
less  comparative  worth  than  that  which  the  occasion  affords.  However, 
certain  established  facts  regarding  the  use  will  not  be  amiss  at  this  time. 
1.  The  employment  of  the  instrument  should  be  conducted  with  a  strict 
antiseptic  regard  in  all  respects,  the  same  as  in  other  operative  procedures 
on  the  urethra  and  bladder.  2.  A  sufficiently  capacious  urethra  and  the 
presence  in  the  bladder  of  not  less  than  five  or  six  ounces  of  clear  fluid  are 
always  needed.  If  the  urethra  be  too  small  it  should  be  dilated  gradually 
and  continuously  with  bougies  until  sufficient  caliber  is  secured.  If  the 
urine  be  clear  the  substitution  of  another  fluid  is  not  indicated.  If  it  be 
cloudy  the  cavity  of  the  bladder  should  be  washed  out  with  a  boric-acid 
solution  (three  per  cent),  or  solution  of  acetate  of  lead  (one  grain  to  the 
ounce),  or  with  sterilized  water,  until  the  outflow  is  clear.  The  presence 
of  blood,  pus,  or  mucus  interferes  with  a  cystoscopic  examination.  The 
lithotomy  position  of  the  patient,  with  the  examiner  sitting  or  standing 
between  the  limbs,  affords  the  best  opportunity  for  examination.  Either 
cocain  anaesthesia  of  the  urethra  and  bladder  or  general  anaesthesia  can  be 
employed,  as  circumstances  require  and  the  patient's  condition  will  permit. 
The  light  should  not  be  turned  on  until  the  instrument  is  introduced  into 
the  bladder  and  the  end  immersed  in  the  fluid  to  prevent  burning  the 
tissue,  and  for  the  same  reason  the  end  of  the  instrument  should  not  be 
brought  in  contact  with  the  wall  of  the  bladder  during  operation.  Ex- 
tended experience  is  required  to  properly  interpret  the  appearances  and 
employ  the  instrument  with  facility. 

Lithotrity,  litholapaxy,  and  lithotomy  are  the  practical  methods  of  relief 
from  stone  in  the  male. 

Lithotrity  is  the  reduction  of  stone  to  fragments  so  small  as  to  allow  of 
their  easy  escape  through  the  urethra  with  the  urine. 

The  Conti'a-indications. — The  contra-indications  to  lithotrity  and  lithol- 
apaxy are  essentially  similar.  These  operations  are  not  admissible  if  the 
bladder  be  sacculated  and  affected  with  extensive  cystitis,  or  if  it  be  ulcer- 
ated or  intolerant  of  tlie  presence  of  instruments.  Eepeated  and  severe 
chills  following  the  introduction  of  instruments  into  the  urethra  or  bladder 
contra-indicate  the  operation.  If  the  organ  contain  morbid  growths,  or  if 
the  patient  be  feeble,  especially  if  the  stone  be  large  and  hard  and  comj^li- 
cated  with  severe  cystitis,  crushing  should  not  be  attempted.  In  the  in- 
stance of  an  enlarged  prostate,  lithotrity  seldom  affords  prompt  or  even  final 
relief,  and  the  enlargement  may  be  so  great  as  to  prevent  proper  litholapaxy. 

The  Prej)aration  of  the  Patient. — It  is  wise  in  all  cases,  although  not 
necessary  in  many,  that  the  patient  rest  in  bed  for  two  or  three  days,  and 
that  the  bladder  be  washed  out  with  an  antiseptic  solution  during  the  time 
before  operation.  In  cases  complicated  with  cystitis,  with  or  without  more 
extended  disease,  this  course  of  action  is  essential.  Bland  food  and  dilu- 
ents are  always  in  order  and  should  be  supplemented  with  iron,  strychnin, 
etc.,  when  the  vital  forces  are  depressed.  The  bowels  should  be  evacuated 
thoroughly,  and  the  urethra  dilated  to  the  proper  capacity  for  safe  instru- 


uim:i;ai'1()N's  dx  tiik  luinakv  bladdkk.  hoi 

mentation  by  sounds.  The  )):itieiit  is  n'(|iiiro(l  to  hold  the  urine  for  iin  hour 
or  two,  and  is  then  phiced  u[)ou  the  back  with  the  pelvis  elevated  ;  the  older 
the  patient  the  greater  the  elevation  should  be.  An  ana3sthetic  may  be 
given  and  should  be  administered  if  it  be  the  intention  to  triturate  the 
entire  mass  at  one  sitting,  or  if  the  patient  l)e  irritaljle,  or  the  bladder 
oversensitive. 

The  liiiroducliun  of  the  Lithatrilc. — The  operator,  having  chosen  and 
well  oiled  a  suitable  instrument,  stands  ujjon  the  right  side  of  the  patient, 
taking  the  penis  in  the  left  hand,  inserts  the  beak,  and  draws  the  member 
upward  nj)on  the  instrument,  which  is  tightly  grasped  by  the  right  hand. 
The  handle  is  then  slowly  raised  until  the  shaft  becomes  vertical,  when  it  is 
transferred  to  the  left  hand,  and  the  fingers  of  the  right  are  placed  on  the 
perina?um  to  follow  the  angle  of  the  beak  as  it  advances  (Fig.  i;350).  The 
weight  of  the  instrument  will 
cause  it  to  sink  low  enough  to 
permit  the  beak  to  engage  the 
opening  of  the  triangular  liga- 
ment, through  which  the  ure- 
thra passes.      A  little  careful 

manipulation,     aided     bv     the        ^      .„-^     t^,.  „       ,,         -.i  ii   i     , 

^  '  -  tiG.  1.3.)0. — Diagram  ot  urethra  wUh  blade  of 

right   hand   on   the  perinteum,  litbotrite  within  it. 

will  cause  it  to  enter  this  i)or- 

tion  of  the  canal,  when  the  handle  of  the  instrument  should  be  taken  by  the 

right  hand  and  allowed  to  fall  slowly  of  its  own  weight  between  the  thighs. 

If  the  instrument  be  now  slightly  pressed  upward,  its  upper  extremity  will 

be  found  to  be  disengaged  and  can  be  easily  rotated  upon  its  long  axis. 

The  Comments. — If  the  prostate  be  enlarged  the  length  of  the  deepest 
portion  of  the  urethra  is  increased,  and  the  enlargement  interposes  an  obstacle 
to  the  progress  of  the  instrument.  The  handle  should  not,  therefore,  be 
depressed  so  rapidly  during  the  latter  stage,  and  the  instrument  should  be 
pushed  farther  upward.  Under  no  consideration  should  any  undue  force  be 
used.  The  weight  of  the  handle  is  of  itself  sufficient,  unless  under  proper 
control,  to  cause  laceration  of  the  soft  urethral  tissues  by  the  advancing  end 
of  the  instrument.  In  the  healthy  bladder  the  instrument  slides  easily 
along  the  floor  to  the  posterior  aspect,  often  hitting  the  stone  in  the  pas- 
sage. In  the  instance  of  an  enlarged  prostate  the  entry  is  not  so  easy,  and 
the  stone  is  often  hidden  behind  it. 

The  Finding  and  Seizing  of  the  Stone. — The  instrument  is  pressed 
upward  in  the  line  of  its  entrance  until  it  reaches  the  posterior  wall  of  the 
bladder,  unless  its  course  be  sooner  interrupted  by  the  stone,  when  the  beak 
is  turned  from  the  stone  and  the  male  blade  withdrawn  ;  then  the  separated 
blades  are  turned  toward  the  stone,  which  is  seized  and  "fixed. 

If  the  stone  be  not  detected  during  the  introduction  of  the  lithotrite, 
quiet  is  maintained  for  a  few  moments  after  the  arrest  of  the  instrument  at 
the  posterior  wall  of  the  bladder.  Then  the  male  blade  is  slowly  withdrawn, 
with  the  beak  upward,  until  quietly  arrested  by  the  neck  of  the  bladder. 
It  is  then  slowly  returned  to  the  former  position,  usually  catching  the  stone 


1162  OPERATIVE   SURGERY, 

en  route.  If  the  stone  be  not  found  at  this  time,  withdraw  the  male  blade 
as  before,  and  with  the  beak  at  45°  to  the  right,  close  the  blades  again. 
Failing  in  this  attempt,  separate  the  blades  and  turn  the  beak  to  the  left  to 
45°  and  close  the  instrument.  If  this  manipulation  fail,  depress  the  handle 
of  the  instrument  so  as  to  raise  the  beak  slightly  from  the  floor  of  the  blad- 
der, and  turn  it  to  the  right  and  left  respectivel}',  as  need  be,  opening  and 
closing  the  blades  in  each  position  in  the  same  cautious  manner.  If  the 
stone  be  small  or  the  prostate  be  enlarged,  the  beak  should  be  turned  down- 
ward in  the  search.  This  is  readily  done  by  depressing  the  handle  of  the 
instrument  sufficiently  to  permit  the  reversed  blade  to  sweep  the  floor 
of  the  bladder  easily,  without  injuring  the  parts.  The  blades  are  then 
opened  and  closed  at  the  various  inferior  aspects  of  the  bladder,  and  in  the 
same  cautious  manner  as  before. 

Another  manoeuvre,  which,  in  the  case  of  small  stones  located  behind  the 
prostate,  will  often  prove  successful,  consists  in  drawing  the  reversed  beak 
outward  until  it  nearly  touches  the  j)rostate,  and  then  separating  the  blades 
by  pressing  the  female  blade  backward  until  it  strikes  against  the  posterior 
wall  of  the  bladder,  the  male  blade  being  held  firmly  in  position ;  raise  the 
handle  until  the  female  blade  rests  lightly  upon  the  floor  of  the  bladder, 
then  draw  it  forward  to  join  the  male  blade,  lightly  touching  the  floor  in  its 
course.  If  a  stone  lies  in  the  line  it  will  be  touched,  and,  moreover,  the 
mucous  membrane  will  not  be  pinched.  It  is  better  that  the  blades  be 
smooth  and  the  beak  be  short  in  these  reversed  movements. 

The  Comments. — The  movements  of  the  instrument  in  searching  should 
be  slow,  and  punctuated  with  slight  intervals,  so  that  the  stone  will  be  dis- 
turbed as  little  as  possible  by  contact  or  the  agitation  of  the  surrounding 
fluids.  Usually  the  female  blade  is  held  firmly  in  position,  while  the  male 
blade  is  opened  and  closed  carefully  for  the  purposes  of  finding  and  seizing 
the  stone.  A  gentle  tap  of  the  handle  of  the  instrument  with  the  finger 
will  sometimes  cause  a  stone  to  fall  within  the  grasp  of  the  open  blades.  If 
practicable,  the  calculus  should  be  crushed  so  fine  at  the  first  sitting  as  to 
prevent  lodgment  in  the  urethra  of  an  impassable  fragment.  Forcible 
instrumental  impingement  on  the  neck  of  the  bladder  should  be  cautiously 
avoided  at  all  times.  Occasionally  the  stone  may  be  so  pressed  against  the 
neck  of  the  bladder  by  the  male  blade  as  to  prevent  its  being  caught,  unless 
the  blade  be  turned  to  one  side  and  cautiously  insinuated  between  the  stone 
and  the  organ.  The  brief  though  sage  advice  of  Sir  Henry  Thompson, 
"  Open ;  pause ;  close — that  is  all,"  establishes  the  safety  of  the  procedure 
when  cautiously  practiced. 

The  crnshing  of  the  stone  follows  promptly  the  catching.  The  stone 
should  be  caught  lightly  and  the  blades  be  slowly  fixed  upon  it  to  avoid  its 
escape  from  the  grasp  in  case  it  be  hard  or  insecurely  caught,  as  may  hap- 
pen if  haste  or  vigor  be  exercised  in  such  instances.  When  secui'ely  seized 
its  dimensions  should  be  noted,  the  beak  turned  upward  and  carried  to  the 
center  of  the  bladder,  as  nearly  as  practicable,  before  crushing,  in  order  that 
freedom  of  the  mucous  membrane  be  assured  and  that  the  fragments  fall 
in  a  handy  place  for  subsequent  treatment  with  the  least  injury  to  the  blad- 


()i'i:KATk)Ns  ox  'I'lii':  ri;i.\Ai;v  i-.i.addkk. 


lir,3 


(lor  wall.  If  the  stone  be  soft  the  jjix'ssure  of  u  steady  turn  of  the  screw  is 
eiillieient  ;  if  hard,  a  quick  vigorous  turn  nuiy  be  needed  to  crush  it.  In 
either  instance,  if  quietly  done,  the  fragments  fall  and  lie  close  at  hand,  and 
can  be  caught  and  crushed  by  repeated  opening  and  closing  of  the  blades 
with  the  same  deliberate  care  and  manipulation  tiiat  characterized  the  jjri- 
niary  act.  That  is,  the  male  blade  should  be  withdrawn  with  the  beak  up- 
ward and  axis  of  the  instrument  unchanged,  then  turned  to  the  right  or 
left  and  carefully  closed,  when,  if  a  fragment  be  caught,  the  beak  is  again 
turned  upward,  away  from  the  wall,  and  the  fragment  crushed.  During  the 
crushing  the  fi-male  blade  must  be  heUl  lirmly  and  at  an  angle  of  4.5°  with 
the  horizon,  and  remain  entirely  passive  (Fig.  1351),  and  the  blades  should 


Fu 


l:,:»l, 


iiiaiiiuT  (if  lidliliiiir  the  liilmirile  when  opening  and  shutting 
in  the  search  for  fragments. 


only  be  separated  sufficiently  to  admit  the  stone  between  them.  If  the  beak 
be  not  turned  away  from  the  stone  before  it  is  opened,  the  stone  may  be  dis- 
placed by  the  separation  of  the  blades. 

Each  siffiitf/,  if  without  an.'esthesia,  should  not  exceed  five  or  ten  minutes ; 
with  it,  a  sitting  can  be  prolonged  until  an  ordinary  calculus  is  reduced  to 
fragments,  usually  from  ten  to  fifteen  minutes.  When  the  sitting  is  com- 
pleted the  blades  must  be  screwed  firmly  together,  so  that  the  instrument 
may  be  withdrawn  without  injury  to  the  urethra.  The  intervals  of  the  crush- 
ing will  depend  upon  the  size  of  the  stone,  its  hardness,  and  more  frequent- 


1164  OPERATIVE  SURGERY. 

ly  upon  the  effect  of  tlie  crushing  upon  the  patient.  Inasmuch  as  the  con- 
ditions differ  greatly,  it  is  impossible  to  lay  down  any  absolute  rules.  The 
surgeon  should  not  repeat  the  operation  until  the  subsidence  of  the  irrita- 
tion produced  by  the  previous  attempts. 

The  Precautions. — The  urethra  should  be  sufficiently  capacious  to  per- 
mit the  wise  use  of  the  lithotrite,  and  the  seizing  and  tearing  of  the  mucous 
membrane  of  the  bladder  should  be  carefully  avoided.  If  the  membrane  be 
caught  the  movement  of  the  beak  toward  the  center  of  the  bladder  will  be 
hindered,  and,  too,  the  sensation  of  seizing  a  soft  instead  of  a  hard  tissue 
may  be  noticed.  However,  the  grasping  of  blood  clots,  pediculated  growths, 
and  possibly  soft  stones  when  coated  with  mucus,  may  simulate  mucous 
membrane  seizure.  The  turning  of  the  beak  away  from  the  bladder  wall 
will  eliminate  these  fallacies.  If  the  patient  be  conscious,  the  seizure  of  the 
mucous  membrane  will  be  known  quickly  by  his  sensations.  Haemorrhage 
is  rarely  sufficiently  severe  to  constitute  a  complication.  Severe  bleeding 
points  to  the  presence  of  a  vascular  growth  or  a  grave  injury  of  the  blad- 
der or  urethra.  Not  infrequently  a  congested  mucous  membrane,  though 
ordinary  care  in  the  manipulation  of  crushing  be  employed,  will  cause  a 
perplexing  haemorrhage.  The  presence  of  detritus  at  the  borders  of  the 
blades,  at  the  time  of  withdrawal,  may  damage  the  mucous  membrane  of 
the  urethra.  However,  if  they  be  firmly  screwed  together,  with  or  without 
a  sharp  tap  with  an  instrument,  the  importance  of  the  fact  is  reduced  to  a 
minimum. 

The  Complications. — The  blocking  of  the  lithotrite  in  the  crushing  of  a 
pasty  stone  may  happen  if  the  groove  for  the  male  blade  do  not  extend  to 
the  lower  end  of  the  instrument.  The  author  experienced  once  an  embar- 
rassing case  of  this  kind,  and  knows  of  a  similar  one  in  the  practice  of  a  col- 
league. The  non-fenestrated  instrument  may  become  blocked  so  as  to  pre- 
vent the  proper  closure  of  the  blades  and  thwart  a  safe  withdrawal  from  the 
bladder.  Perineal  or  suprapubic  cystotomy,  with  exposure  of  the  beak  and 
removal  of  the  obstruction,  followed  by  removal  of  the  stone  through  the 
opening,  is  the  solution  of  the  dilemma.  If  the  beak  of  the  instrument  be 
broken,  cystotomy  offers  prompt  relief.  If  the  bladder  be  torn  through,  and 
the  fact  be  recognized,  laparotomy  with  repair  of  the  tear  is  indicated,  the 
same  as  in  lithotomy  (page  1200).  If  the  deep  urethra  be  ruptured,  perineal 
section  is  called  for.  The  lodgment  in  the  urethra  of  a  fragment  of  stone 
at  the  time  of  or  immediately  subsequent  to  the  operation  may  cause  much 
trouble,  especially  if  it  prevent  the  flow  of  urine. 

The  After-treatment. — After  the  completion  of  the  sitting  the  patient  is 
given  an  anodyne,  and  hot  fomentations  are  applied  to  the  abdomen,  and  he 
is  caused  to  remain  in  the  recumbent  posture  for  at  least  twenty-four  hours 
subsequent  to  the  operation,  even  to  the  extent  of  lying  on  his  side  during 
micturition.  If  urethral  fever  or  retention  occur,  or  a  mild  cystitis  super- 
vene, the  length  of  the  time  of  confinement  in  bed  and  the  treatment  should 
conform  to  the  requirements  which  these  conditions  impose. 

The  Comments. — Lithotrity  is  practiced  much  less  than  formerly,  lithola- 
paxy  being  done  instead.     The  pain  and  perplexity  incident  to  the  block- 


Ol'KKA'I'lONS   ON    TIIK    nnNAUV    lihA  DDllli. 


1165 


iii2[  of  tlio  iirotlirii  hy  ;in  (.'sc'!ii)iii<,'  fr;i_<,nnoiit,  cspcciully  wlicn  l:irf,'o  and  aiigu- 
liir,  and  the  k'avin<^  beliiiui  of  a  piece  for  future  development  of  Htone,  are 
sequels  to  be  anticiitateil  in  this  operation  no  matter  how  carefully  it  may 
be  practiced.  The  repeated  distention  of  tiie  bladder  by  water,  at  the  time  of 
crushini::,  with  the  idea  of  causing  the  dis(;hargo  of  tlie  fragment  by  the  sud- 
den and  forcible  outrusli  of  the  fluid,  exposes  the  patient  to  the  danger  of 
ru])ture  of  the  organ — a  fact  which  is  emphasized  by  the  reported  liap])en- 
ings  of  this  accident  from  the  stereotyped  plan  of  the  introduction  of  water 
during  the  crushing  process.  At  all  events,  only  operators  competent  to 
detect  and  crush  the  fragments  so  as  to  preclude 
these  accidents  should,  without  some  unavoidable 
reason,  practice  lithotrity. 

Tlte  RcsHltii. — Tiie  general  rate  of  mortality  is 
about  II  per  cent.  The  liability  of  retention  in  the 
bladder  of  one  or  more  fragments  exposes  the  ])atient 
to  a  comparatively  ])rompt  return  of  the  trouble. 

Litholapaxy  (rapid  lithotrity),  or  the  crushing  and 
washing  out  of  a  stone  at  a  single  sitting,  has  largely 
supplanted  lithotrity. 

Tlie  i7istruments  nsuaUy  employed  in  this  pro- 
cedure are  the  lithotrites  of  Thompson  or  Bigelow, 
as  shown  in  Figs.  1352  to  1355,  the  latter  being  iu 
quite  common  use.  The  blades  of  lithotrites  differ 
in  their  grinding  surfaces  from  a  simple  roughening 
to  a  well-marked  denticulatiou.     The  blades  of  Bige- 


FiG.   1352. — 'riuiiniison's 
lithotrite. 


Fig.  1354. — Xon-feiicst rated  jaws. 


low's  instrument  present  appearances  peculiar  to  themselves  (Figs.  1355  to 
1357).  The  instrument  used  by  Keyes  is  of  a  stronger  pattern  than  is  com- 
monly employed,  and  is  provided  with  a  large  wheel  at  the  end  that  a 
greater  force  may  be  quickly  applied.     The  blades  are  fenestrated   (Figs. 


1166 


OPERATIVE   SURGERY. 


1358  and  1359),  and  are  so  constructed  that  the\'  will  not  clog.  Forbes  has 
devised  a  lithotrite  of  unusual  strength,  of  simple,  durable  mechanism,  and 
safe  and  effective  crushing  power  (Fig.  1371,./).     In  all  erushiug  operations 


Fig.  1356. — Bigelow"s  non-fenestrated  blades. 


Fig.  1o57. — Biii;elow".s  fenestrated  blades. 


Fig.  13.j5. — Bigelow's 
lithotrite. 


Figs.  1358,  1359. — Reyes's  modified  blades. 


the  operator  should  possess  lithotrites  of  two  or  three  sizes  and  of  different 
patterns  and  power,  to  enable  him  to  compW  with  the  demands  of  individual 
cases,  as  modified  by  the  hardness  and  size  of  the  stone,  size  of  the  urethra, 
etc.     For  crushing  large  and  hard  stones  a  fenestrated  blade  should  be  era- 


OI'KUA  rioXS   O.N    TIIH    IKLNAKV    I'.LA  DDKK. 


1167 


ployed.  If  the  stune  be  small  uml  friahli-,  tlie  bhidcs  iiuiy  be  roughened 
only,  with  tlio  male  blade  much  the  smaller.  A  non-fenestrated  or  "scoop" 
lithotrite  can  be  used  to  crush  tlie  smaller  fragments.    The  larger  and  harder 


I'k;.   loOO. — 'i'li(jini)son"s  evaeiialor. 

the  concretion,  the  stronger  slionld  be  the  instrument  employed.  In  addi- 
tion to  the  instruments  fur  crushing,  the  operator  must  be  provided  with  an 
evacuator  or  washer.     The  Thompson  washer  is  admirable  (Fig.  13G0),  and 


l>ii;:olo\v's  evacuator. 


the  latest  pattern  of  Bigelow  leaves  but  little  to  be  desired  in  this  respect 
(Fig.  1361).  Otis's  washer  (Figs.  1362  and  1363)  is  simple,  cheap,  and  effi- 
cient ;  so  also  is  Chismore's  (Fig   13G4). 


1168 


OPERATIVE   SURGERY. 


The  evacuating  tubes  of  Bigelow  (Fig.  1365),  or  their  modifications,  com- 
plete the  outfit.  The  spiral-tipped  tube  of  Warren  (Fig.  1366)  and  the 
straight,  open-ended  one  of  Keyes   (Figs.  136 T  and  1368)   are  thought  to 


Fig.  136.3. — Otis"s  evacuaior.  iuverted. 


facilitate  the  discharge  of  the  detritus,  while,  in  the  latter  example  espe- 
cially, the  lining  membrane  of  the  urethra  is  not  exposed  to  injury  from  a 
fragment  lodged  in  the  eye  of  the  instrument  during  its  withdrawal  from. 


the  bladder.     The  size  of  the  tube  commonly  employed  varies  from  16  to 
18,  English  scale.     Those  of  different  sizes  and  patterns  should  be  at  hand. 


OPERATIONS   ON    TIIK    I'KINAliV    I'.LADDIIK. 


1169 


Fui.  1365.— Bii,a>- 
low's  evacuat- 
ing tubes. 


The  jn-eparatory  Ircatinent  consiriU  in  alli-viatini:  all  bud  symptoms  de- 
pendeut  upou  the  existence  of  the  stone,  and  in  i)i('[)arin<,'  the  urethra  for 

receiving  the  instruments  by  increasing  its 
size  if  necessary,  and  subduing  any  undue 
sensibility  of  it.  The  measures  employed 
|)re]niratory  to  litliotrity  are,  of  course,  of 
e(|ual  imjiortance  in  this  operation. 

The  Operation. — An  assistant,  whose  only 
duty  is  to  empty  the  washer  and  adjust  it, 
should  be  provided.  In  other  matters  the 
te'chuique  differs  in  no  essential  regard  from 
that  of  lithotrity  up  to  the  time  of  washing 
out  the  bladder. 

The  method  of  introduction  of  the  litho- 
trite  and  the  process  of  catching  and  crushing  the  stone  are  similar  in  this 
operation  to  the  ordinary  method,  except  that  the  crushing  process  is  inter- 
rupted by  the  introduc- 
tion of  the  evacuating 
catheter  as  soon  as  the 
stone  is  well  broken, 
which  may  be  within 
five  or  ten  minutes 
after  the  introduction 
of  the  lithotrite,  de- 
pending, of  course,  up- 
on the  success  attend- 
ing the  efforts  of  the 
operator.  A  well-lu- 
bricated aseptic  evacu- 
ating catheter  is  then 
passed  down  to  the 
prostatic  urethra,  but 
not  into  the  bladder, 
closely  hugging  the 
urethral  roof  and  care- 
fully avoiding  the  tri- 
angular ligament  as  it 
passes.  The  washer  is 
then  attached  to  the 
catheter  at  this  situa- 
tion to  avoid  the  en- 
trance of  air  into  the 
bladder.  Before  attach- 
ing the  washer  it  is 
filled  with  a  warm  bo-   Fic.  i;!(i(J.— Wai- 

ric-acid  solution  or  with        IT"  ^  ,   spn-al- 

tipped    evacu- 
sterilized  water.      The       atinsr  tube. 


Fig.  1:}67. — Kcyes's 
straight  evacuat- 
ing tube  and 
guide. 


Fig.  1368.— Keyes's 
curved  evacuat- 
ing tube  and 
guide. 


1170 


OPERATIVE   SURGERY. 


air  in  the  catheter  while  it  is  thus  located  will,  if  fluid  be  forced  gently 
into  it,  pass  upward  through  tlie  fluid  in  the  washer  to  the  air  trap  above, 
from  which  it  is  excluded  before  the  evacuating  tube  is  carried  on  into 
the  bladder.  If  now  the  elastic  bulb  be  alternately  slowly  compressed  and 
expanded,  the  changing  current  thus  produced  will  wash  the  fragments 
from  the  bladder,  and  their  weight  will  precipitate  them  into  the  glass 
receiver  beneath   (Fig.   1.369).      After  expansion  of  the  bulb   is  complete. 


Fig.  I.jG'J. — Showing  the  manner  (^f  holding  the  bulb.     The  left  hand  hold-  ilie  weight 
while  the  right  manipulates  it. 

an  interval  of  a  few  seconds  sliould  elapse  before  pressure  is  again  made, 
in  order  to  allow  all  of  the  fragments  in  the  tube  to  drop  into  the  receiver. 
If  the  outflow  cease  suddenly,  the  entrance  of  the  tube  is  likely  blocked 
with  a  large  fragment,  or  by  the  sucking  in  of  the  mucous  membrane.  If 
all  the  fragments  be  not  removed — which  can  be  ascertained  by  the  intro- 
duction of  a  searcher,  or  known  by  the  'click"  of  a  fragment  against  the 
evacuating  catheter  at  the  time  of  washing,  and  by  the  audiphone — the 
process  of  crushing  is  again  resorted  to,  and  the  resulting  comminutions 
treated  as  before  until  the  entire  stone  is  removed.  The  last  fragments  not 
infrequently  elude  the  grasp  of  the  instrument,  and,  were  it  not  that  they 
can  be  heard  to  strike  the  evacuating  catheter  when  the  water  flows  out- 
ward, their  existence  might  not  be  known.  If  the  curved  tube  be  used  the 
beak  should  be  turned  from  side  to  side  to  present  its  eye  to  difi'erent  as- 


OPERATIONS  ON  THE   URINARY   BLADDER.  1171 

pects  of  tlie  hhiddcr.  'I'lio  square-t'iuk'd  tube  of  Keyes  (Fig.  Voi'u)  is  passed 
just  beyond  the  neck  of  tlie  bladder,  and  its  external  extremity  is  well  lowered 
between  the  thighs.  The  author  has  employed  with  seeming  advantage  an 
evacuating  catheter  with  an  additional  large  eye  at  the  convex  surface. 
With  tins  arrangement  it  has  seemed  easier  to  secure  the  final  small  frag- 
ments than  without  it,  especially  if  the  bulb  were  very  slowly  manipulated. 
However,  it  is  better  sometimes  to  allow  these  fragments  to  remain  until  the 
j)atient  has  recovered  from  tlie  o])eration,  and  then  seek  for  them  again,  than 
to  continue  indelinitely  the  attempt  to  secure  the  last  one  at  the  first  sitting. 
Small  fragments  that  escape  detection  are  not  infrequently  passed  with  the 
urine  within  four  or  the  days  after  the  operation. 

The  limit  of  time  to  which  the  first  crushing  may  be  prolonged  is  not  an 
arbitrary  one;  an  hour  or  two  is  not  unusual,  and  even  a  longer  time  may  be 
employed.  However,  an  hour  is  a  fair  estimate  of  time  to  occupy  in  the 
common  class  of  cases. 

I'he  Conunents. — In  profound  anaesthesia  with  deep  breathing,  the  cur- 
rent of  the  Huid  should  be  the  reverse  of  that  of  the  respiratory  current — 
i.  e.,  running  in  with  expiration,  running  out  with  inspiration.  The  open- 
ing of  the  evacuating  catiieter  should  be  raised  somewhat  above  the  frag- 
ments, and  suction  should  not  be  permitted  until  they  are  settled  in  place. 
The  absence  of  the  "  click"  during  washing  is  the  best  proof  of  the  with- 
drawal of  all  the  fragments.  Auscultation  of  the  abdomen  or  instrument 
employed  in  the  search  will  enable  one  to  detect  the  faintest  sound.  A 
thudlike  sound,  attended  with  brief  arrest  of  the  flow,  is  suggestive  of  the 
indrawing  at  the  eye  of  the  catheter  of  the  mucous  membrane  of  the  bladder. 

llie  Precautions. — The  entrance  of  air  to  the  bladder  during  the  wash- 
ing out  should  be  avoided,  since  its  presence  there  causes  a  churning  sound 
which  obscures  the  click  of  small  fragments  and  hinders  a  proper  flushing 
of  the  viscus.  The  air  can  be  removed  by  slow  manipulation  of  the  bulb 
with  the  end  of  the  tube  at  the  uppermost  portion  of  the  bladder.  The 
presence  during  withdrawal  of  the  catheter  of  a  stone  in  the  eye  of  the 
instrument  may  lacerate  the  urethra;  therefore,  a  suspicion  of  such  a  fact 
calls  for  a  clearing  out  of  the  instrument  before  its  withdrawal.  The  fickle- 
ness of  rubber  goods  emphasizes  the  wisdom  of  having  two  evacuators  at 
places  far  removed  from  the  base  of  surgical  supplies,  as  the  writer  once 
had  occasion  to  know.  The  passage  of  an  evacuating  catheter  with  a  large 
eye  along  the  urethra  Tuust  be  done  cautiously,  or  the  mucous  membrane 
will  be  cut  by  the  border  of  the  eye.  In  fact,  it  is  better  to  close  the  open- 
ing in  advance  with  an  obturator,  which  can  be  easily  removed  after  the  in- 
troduction, than  to  incur  the  danger  of  injury  by  omitting  closure.  The 
complications  of  crushing  are  stated  under  Lithotrity  (page  llG-l:). 

Tlie  Affer-ireatmexf. — After  the  operation  the  patient  is  kept  quiet  in 
bed  and  well  wrapped ;  if  retention  occurs,  it  is  relieved  by  a  catheter.  Vide 
Lithotrity. 

The  iSequels. — Litholapaxy  has  various  sequels — rigors,  retention  of  urine, 
cystitis,  epididymitis,  atony  of  the  bladder,  suppression  of  urine,  etc. — each 
of  which  should  be  anticipated,  and  treated  on  general  principles. 
80 


11Y2  OPERATIVE  SURGERY. 

The  Results. — Under  ordinary  circumstances  the  patient  will  be  up 
and  around  at  the  end  of  a  week  or  ten  days.  The  rate  of  mortality  is 
from  l\  to  7  per  cent,  depending  on  the  character  of  the  case  and  the 
skill  of  the  operator.  ]\arely  a  return  of  the  stone  is  experienced  except 
as  the  result  of  the  initial  cause.  The  results  are  better  in  women  than 
in  men. 

Litholapaxy  in  Children.— Until  quite  recently  it  has  been  regarded 
as  inexpedient  and  even  positively  dangerous  by  some  to  employ  lithol- 
apaxy in  children.  But,  inasmuch  as  nearly  half  the  cases  of  calculi 
occur  in  children,  and  the  outcome  of  the  operation  was  so  favorable  in 
adults,  the  objectionable  barrier  of  youth  was  quite  promptly  broken  down 
by  the  favorable  results  of  the  operation  when  carefully  practiced  at  tbe 
tender  age  by  experienced  hands.  It  was  soon  found  tbat  the  diameter  of 
the  urethra  in  the  youth  could  be  as  safely  and  suitably  increased  in  size  as 
in  the  adult.  Also  that  the  urethra  and  bladder  of  the  young  are  very 
tolerant  of  instrumentation.  While  it  is  true  that  the  mucous  membranes 
of  the  young  are  more  delicate  than  those  of  the  old,  still,  the  employment 
of  extra  caution,  and  the  absence  of  concomitant  complications  of  stone  in 
children,  together  with  their  stronger  inherent  tendency  to  recovery,  made  the 
final  outcome  in  them  quite  as  good  as  in  the  most  favorable  adult  cases.  In 
children,  instruments  of  a  smaller  caliber  are  required  and  a  due  recognition  of 
the  higher  position  of  the  bladder  is  needed  to  safely  secure  the  desired  con- 
summation in  both  crushing  and  cutting.  But  these  anatomical  peculiari- 
ties of  youth  make  lithotomy  all  the  more  difficult.  Added  to  this  is  the 
danger  of  irreparable  injury  of  the  seminal  ducts  in  perineal  lithotomy. 
The  preparation  of  the  patient  and  the  general  and  special  technique  of  the 
procedure  is  similar  to  that  in  adults.  The  complications  are  less  frequent, 
though  their  avoidance  and  remedy  is  equally  important. 

The  Results. — In  1,213  cases  performed  by  eleven  operators  the  average 
mortality  was  2.23  per  cent  (White  and  Martin). 

Combined  Crushing  and  Evacuation. — The  idea  of  the  possible  utility  of 
such  a  combination  occurred  to  us  in  1884,  after  a  somewhat  annoying  effort 
on  our  part  to  seize  the  "  last  fragment,"  the  existence  of  which  could  be 
easily  and  quickly  demonstrated  by  the  characteristic  click  against  the  eye 
of  the  evacuating  catheter  during  the  washing-out  process.  We  also  recalled 
the  fact  that  on  other  occasions  the  suction  force  of  the  washer  had  been 
temporarily  arrested  by  the  closure  of  the  eye  of  the  evacuating  catheter  by 
a  fragment  of  calculus.  In  the  construction  the  male  blade  of  an  ordinary 
lithotrite  was  modified  to  fit  the  anterior  wall  of  the  ordinary  evacuating 
catheter,  which  is  lined  with  a  brass  tube.  The  washer  was  easily  con- 
nected with  the  instrument,  as  shown  by  the  cut  (Fig.  1370).  It  was  not 
expected  that  this  instrument  would  supplant  the  lithotrite.  The  idea  was 
to  crush  the  stone  at  the  first  introduction  of  the  lithotrite  as  effectually  as 
practicable,  and  then  to  introduce  the  combined  instrument  instead  of  the 
ordinary  evacuating  catheter.  By  means  of  this  the  detritus  could  be 
removed  from  the  bladder,  and  such  of  the  remaining  fragments  as  were 
caught  in   the   throat  of   the   instrument  could  be  crushed   and   likewise 


OPERATIONS   OX    TIIK    URINAUY    I'.LADDKR. 


1173 


removed.  It  thus  was  possible  to  avoid  the  iiitercliaiige  of  instruiiients 
incideut  to  repeated  crusliiiigs.  With  an  assistant  to  niaiiipidate  the  washer, 
the  operator  can  devote  his  entire  attention  to  crushing  the  fragments 
cauglit  in  the  throat  of  the  instrument. 

Cliismore  has  done  much,  indeed,  by  practice,  precept,  and  ingenuity,  to 
establish  on  a  still  stronger  basis  the  operation  of  litliolai)axy.  lie  divides 
the  cases  practically  into  two  classes :  1,  those  in  which  the  prostate  gland 
is  normal  in  size ;  2,  those  in  which  it  is  enlarged, 
and  remarks  :  "In  the  former  the  operator  may  con- 
fidently rely  on  clearing  the  bladder  at  one  sitting ; 
in  the  latter  several  crushings  may  be  required,  and 
the  patient  should  be  distinctly  informed  of  that 
fact  before  the  operation,  in  order  that  he  may  not, 
in  his  disappointment  at  not  being  entirely  relieved 
at  once,  refuse  to  submit  to  further  attempts." 

Regarding  the  use  of  his  outfit  and  the  method 
of  practice  he  writes  (September  12,  1900)  us  as 
follows : 

"  My  essential  instruments  for  litholapaxy  are 
three :  A  combined  crushing  and  evacuating  litho- 
trite  (Fig.  1.371,  fZ,  with  enlarged  blades);  an  aspirator, 
very  simple  in  construction  (Figs.  1364  and  1371,  t), 
without  stopcocks  and  of  such  a  shape  as  to  fit  the 
hand,  and  when  coupled  to  the  lithotrite  it  forms 
an  excellent  handle  not  interfering  in  the  least  with 
delicacy  of  touch  ;  and  an  automatic  hammer  (Fig. 
1371,  g)  that  when  vigorously  applied  to  the  litho- 
trite will  crush  the  hardest  stone.  I  have  also 
modified  Sir  Henry  Thompson's  searcher,  making 
the  shaft  to  cori-espond  in  length,  curve,  and  gradu- 
ation marks  with  those  of  the  lithotrite,  shaping 
the  external  end  of  the  handle  so  as  to  fit  my  asiii- 
rator,  and  providing  it  with  a  movable  index. 

"For  the  idea  of  an  evacuating  lithotrite  I  am 
indebted  to  you.  Several  of  the  older  lithotrites 
had  catheters  in  one  or  the  other  of  the  blades,  but 
they  were  used  solely  for  the  purpose  of  increasing 
or  diminishing  the  amount  of  fluid  in  the  bladder 
during  search  or  operation. 

"The  catheter  in  my  instrument  is  in  the  male 
blade,  the  external  end  of  whicli  is  made  to  fit  my 

aspirator,  so  that  I  can  avail  myself  of  the  to-and-fro  current  during  aspira- 
tion to  draw  a  stone  or  its  fragments  into  the  jaws — the  first  lithotrite,  I 
believe,  to  make  use  of  this  principle. 

"  The  lithotrite  is  carefully  prepared,  by  taking  it  apart,  coating  the  shaft 
of  the  male  blade  with  lanolin  ointment  containing  ten  grammes  boric  acid 
to  the  ounce,  and  putting  the  instrument  together,  working  it  back  and 


Fk;.  1;!:0.— The  author's 
combined  instrument. 


1174 


OPERATIVE   >L'K(TEIiY, 


Fig.  1371.— Instruments  employed  by  Chismore  in  litholapaxy.    Also  Forbes's  litliotrite. 

a.  Pinion  to  lithotrite.  b.  Cap  for  hand  pressure,  c.  Detritus  dislodger.  d.  Chismore's 
lithotrite  with  magnified  blades,  e.  Evacuating  tube.  /.  Keyes's  syringe.  ^.  Auto- 
matic hammer,  h.  Curved  steel  sound,  i.  Chismore's  washer,  also  Fig.  Idb4. 
j.  Forbes's  lithotrite  with  magnified  blades. 


OPERATIONS  ON   TUK    UKINAItV    HLADDKK.  1175 

forth  until  the  ointiueut  is  uvciily  (ii.stribiitcd  between  the  tubes,  making  a 
packing  impervious  to  air  or  water. 

"  A  patient  with  normal  prostate  is  placed  on  the  operating  table  on 
his  back,  buttocks  well  down  to  the  eiul,  thighs  moderately  Hexed,  and 
the  feet  supported.  A  half  drachm  of  a  four-per-cent  solution  of  cocain  is 
thrown  into  the  deep  urethra  by  means  of  a  Keyes  syringe  (Fig.  137 1, y),  a 
No.  13  Van  I>ureu  (h)  sound  is  gently  2)assed,  and  the  size  and  condition  of 
the  urethra  noted.  If  a  preliminary  meatotomy  is  necessary  it  is  done 
under  cocain. 

"Gently  introduce  the  searcher  (Fig.  1343)  and  empty  the  bladder,  even 
if  the  patient  has  just  voided  his  urine.  If  this  is  not  done  there  may  be 
several  ounces  remaining  and  the  operator  be  greatly  misled  thereby.  The 
aspirator  is  tilled  with  a  warm  solution  of  boric  acid,  coupled  to  the  searcher, 
and  about  three  fluid  ounces  injected.  Careful,  methodical  search  is  then 
made  over  every  part  of  the  bladder  that  can  be  reached.  In  such  cases  the 
stone  is  usually  found  in  the  region  of  the  base  of  the  bladder  to  one  side  of 
the  median  line — most  frequently  to  the  right,  A  negative  result  should  not 
always  be  taken  as  conclusive,  especially  if  the  patient  is  nervous  and  appre- 
hensive. Manipulation  under  such  circumstances  should  not  be  too  pro- 
longed. It  is  better  to  defer  giving  an  opinion  until  a  subsequent  visit, 
when  a  better  judgment  can  be  formed.  Several  times  it  has  happened  to 
me  to  easily  find  a  stone,  and  not  always  a  small  one  at  that,  which  has 
eluded  search  on  the  first  trial.  If  a  stone  is  found,  note  carefully  its 
location — feel  for  its  farthest  border — and,  having  found  it,  set  the  index 
on  the  searcher  at  the  meatus.  Then  strive  to  approximate  its  size  by 
withdrawing  the  searcher  until  its  nearest  border  is  felt.  Note  the  angle 
which  the  shaft  of  the  searcher  makes  with  the  axis  of  the  body.  The 
bladder  is  once  more  emptied  through  the  searcher,  and  from  an  ounce 
and  a  half  to  three  ounces  of  warm  four-per-cent  solution  of  cocain  is  injected 
through  it  by  means  of  a  rubber  tip  penis  syringe.  It  is  much  more  con- 
venient to  work  in  a  small  bladder  than  a  large  one ;  more  than  three  fluid 
ounces  are  seldom  required — less  than  that  quantity  is  often  better.  While 
this  is  taking  eft'ect,  the  lithotrite  and  its  appurtenances  are  placed  within 
convenient  reach,  a  large  pan  of  warm  solution  of  boric  acid  prepared,  the 
aspirators  (two)  filled,  and  the  tubes  laid  out. 

"An  assistant  is  needed  to  apply  the  pinion  (Fig.  1371,  a),  when  required, 
and  to  empty,  refill,  and  hand  the  aspirators.  But  I  have  often  done  the 
operation  alone.  By  this  time — about  five  minutes  after  the  injection  of  the 
cocain — the  bladder  is  anaesthetized.  The  lithotrite  is  then  properly  warmed, 
anointed,  and  gently  introduced.  Too  much  care  can  not  be  taken  in  this  step 
of  the  operation.  Holding  it  lightly,  gradually  slip  it  along  the  urethra  until 
the  anterior  triangular  ligament  is  reached  (Figs.  1378  and  1379).  If  there 
is  obstruction  wait  patiently.  Gently  search  along  the  face  of  the  ligament 
for  the  urethral  opening.  Let  it  go  its  own  way,  do  not  try  to  force  it,  and 
presently  spasm  will  relax,  and  it  will  slip  in  without  pain  or  injury  to  the 
delicate  and  resentful  structures.  Once  in  the  bladder,  I  carry  the  end  of 
the  closed  lithotrite  a  little  bevond  the  farthest  border  of  the  stone.    Observe 


1176  OPERATIVE  SURGERY. 

that  the  shaft  is  at  the  same  angle  with  the  axis  of  the  body,  as  noted  by  the 
searcher.  Open  the  instrument  to  the  size  of  the  stone,  or  a  little  more, 
reverse  the  beak  to  the  locality  of  the  stone,  and,  on  closing  the  jaws,  it  is 
caught  usually  at  the  first  trial.  If  failure  attends,  I  seek  again  and  again 
until  success  is  attained.  Should  1  not  be  able  to  readily  grasp  it  in  this 
manner.  I  open  the  jaws  to  the  fullest  extent  that  the  bladder  will  permit 
without  force,  gently  push  the  bladder  upward  with  tlie  female  blade,  at  the 
same  time  depressing  the  jaws  by  elevating  the  handle  of  the  lithotrite,  thus 
imparting  to  the  viscus  a  V  shape,  with  the  open  jaws  of  the  instrument  in 
the  angle  of  the  trough.  Then,  couj^ling  on  the  aspirator  (filled),  compress 
the  bulb  and  throw  an  ounce  or  more  of  its  contents  in.  This  creates  a 
current  which  raises  the  stone  up,  when,  smartly  relaxing  the  bulb,  the 
returning  flow  sucks  the  stone  into  the  jaws.  Sometimes  these  manoeuvres 
have  to  be  repeated  many  times  before  the  stone  is  caught,  varying  the  angle 
of  the  shaft,  and  lateralizing,  or  even  reversing,  the  jaws.  Each  time  fluid 
is  withdrawn.  Before  again  compressing  the  bulb  it  is  used  as  a  handle  to 
the  lithotrite.  The  jaws  are  gently  closed  to  learn  if  the  stone  be  within 
its  grasp. 

"  Having  secured  the  stone,  and  before  grasping  it  tightly,  move  it  in  all 
directions  to  be  sure  you  have  not  included  any  living  tissues,  and  also  to 
ascertain  if  there  be  more  than  one.  If  free,  carry  it  to  the  center  of  the 
bladder  and  try  to  crush  it  by  means  of  the  hand  cap  (Fig.  13T1,  b).  If  too 
firm  for  that,  the  assistant  inserts  the  pinion  (a)  and  gradually  puts  on  the 
force  until  the  stone  yields  or  again  proves  too  strong.  In  this  case  the 
assistant  holds  it  as  firmly  as  possible  with  the  pinion  while  the  operator 
removes  the  hand  cap  and  fixes  the  automatic  hammer  (g).  With  the  ham- 
mer in  the  hollow  of  the  right  hand  he  makes  firm  pressure  in  a  line  with 
the  shaft  of  the  lithotrite.  This  pushes  the  piston  a  little  inward  and  '  sets 
it.'  Then  with  the  first  and  second  fingers  of  the  same  hand  he  brings  the 
lugs  smartly  home,  which  releases  the  hammer  and  delivers  the  stroke.  He 
repeats  the  manoeuvres  as  often  as  needed,  and  it  will  be  a  tough  stone, 
indeed,  that  does  not  yield  to  the  shattering  blows.  During  this  procedure 
the  left  hand  grasps  the  fluted  handle  of  the  female  blade  of  the  lithotrite, 
controls  the  position  of  the  jaws  within  the  bladder,  and  also  furnishes  the 
needed  counter-resistance  to  the  force  of  the  hand  cap  (b),  pinion  («),  or 
hammer  (g).     Practically  the  hammer  will  seldom  be  needed. 

"  Having  broken  the  stone,  the  fragments  are  much  easier  dealt  with, 
since  they  gravitate  to  the  locality  originally  occupied  by  the  stone,  where 
they  can  be  readily  found. 

"  If  the  stone  is  small,  the  aspirator  will  remove  the  fragments  through 
the  lithotrite  as  fast  as  it  is  crushed.  If  it  is  a  large  one,  it  is  better  to 
remove  the  lithotrite  from  time  to  time  and  introduce  as  large  a  tube  as  will 
pass  without  undue  tension,  and,  with  the  aspirator,  wash  the  debris  out 
through  it.  If  the  detritus  be  impacted  in  the  blades  or  lumen  of  the 
instrument  the  disengager  (c)  is  introduced  and  the  obstacle  is  dislodged. 

"  During  this  time  the  patient  should  have  suffered  but  moderate  pain. 
If  pain  becomes  troublesome,  open  the  stopcock  in  the  lithotrite,  let  out  the 


OI'i:UAri()XS   ON    TIIK    LKINAia     I'.LA  DDKK.  II77 

contents  of  tlu'  bladder,  juid,  without  hesitation,  inject  one  and  a  lialf  to 
three  ounces  of  fresh  cocain  solution.  1  have  frequently  kept  in  the  blad- 
(Ut  a  fdui'-per-ccnt  sojiitioii  for  inoi'c  than  an  hour,  and,  on  occasions,  over 
three  hours,  witiiout  toxic  ell'cct.  \\  hen  the  whole  of  the  clone  is  removed 
a  few  bulbs  of  borated  solution  ai'e  thrown  in  and  aUowed  to  escape,  for  the 
pur})ose  of  removing  the  cocain,  taking  care  not  to  distend  the  bladdei*. 
The  patient  nniy  then  dress  and  go  home,  with  directions  to  remain  in 
bt'il  until  the  soreness  and  irritation  have  passed  away,  to  save  all  urine 
passed  for  insj)ection,  and  to  send  for  medical  aid  in  case  of  chill  or  ])ain. 

"  Special  Precautions. — If  the  beak  of  the  lithoti'ite  is  reversed,  the  oper- 
ator shonld  always  bear  in  mind  the  fact  that  the  line  of  the  reflection  of  the 
recto-vesical  fold  of  the  i)eritonieuni  (Figs.  1378  and  1405)  fixes,  in  a  measure, 
that  portion  of  the  bladder  to  which  it  is  attached.  Below  and  above  this 
transverse  line  the  jaws  of  the  instrument  will  easily  push  the  walls  of  the 
viscns  before  them,  when,  if  closed,  a  fold  of  the  bladder  is  almost  surely 
included  in  the  bite.  A  knowledge  of  this  fact,  together  with  the  easily 
recognized  'feel,'  will  serve  to  prevent  injury  from  this  source.  If  both 
jaws  happen  to  be  below  the  vesico-rectal  fold,  on  attempting  to  open  the 
instrument  a  false  sense  of  sacculation  is  the  result. 

"  The  After-treatment. — Little  need  be  said  of  after-treatment.  When 
the  whole  of  the  stone  is  removed  there  is  rarely  any  trouble.  Shonld  any 
fragments  be  left  too  large  to  pass  the  urethra  they  will  give  notice  of  their 
presence  by  pain  and  frequency  of  micturition,  and  the  urine  will  continue 
cloudy  with  pus  and  mucus.  I  have  found  the  sensations  of  patients  very 
reliable  as  to  a  remaining  piece.  When  they  declare  that  they  '  feel  a  piece ' 
there  is  nearly  always  one  present,  and  it  shonld  be  sought  for  as  soon  as 
irritation  from  j^revious  operation  has  subsided.  An  attack  of  urethral 
fever  may  come  on  at  the  first  voiding  of  urine,  especially  if  the  deep 
urethra  has  been  stretched  much  during  the  operation,  but  it  subsides  for 
the  most  part  during  the  first  twenty-four  hours.  A  little  morphin  and 
quinine  is  all  that  is  required. 

"  Small  fragments  become  slippery  with  a  coating  of  pus  and  mucus,  and 
are  voided  with  but  little  suffering.  Often  the  action  of  the  aspirator  is  so 
thorough  that  not  a  single  grain  of  calculus  is  left.  When  a  small  fragment 
is  suspected  it  is  well  to  let  the  patient,  when  the  bladder  is  full,  stand 
upright  while  a  full-sized  litholapaxy  catheter  is  gently  passed.  A  small 
piece  or  pieces  may  often  be  got  rid  of  by  this  simple  method.  Such  cases 
are  usually  u]i  and  about  in  two  or  three  days.  I  have  nevei-  had  a  case  of 
chronic  cystitis  follow  the  complete  removal  of  a  stone  when  the  prostate 
was  normal,  nor  have  I  yet  had  a  fatal  result,  or  any  severe  complication? 
follow  a  crushing  operation  in  this  class  of  cases. 

" /;i  cases  where  the  prostate  gland  is  enlarged  and  catheter  life  is  begun, 
the  proceeding  is  the  same,  save  that  the  ]iatient  is  plaiidy  told  that  several 
sittings  may  be  required  to  free  his  bladder  from  stone.  Where  the  mass  of 
the  hypertrophied  prostate  encroaches  upon  the  bladder,  it  removes  a  consid- 
erable area  from  the  direct  command  of  the  lithotrite,  and  pieces  may  lodge 
there  in  such  a  way  that  prolonged  manipulation  will  not  secure  them.     In 


1178 


OPERATIVE  SURGERY. 


'\ 


view  of  the  fact  tliat  the  urethra  must  be  regukirly  traversed  by  the  catheter 
at  short  intervals  after  the  operation,  I  seize,  crush,  and  remove  as  much  as 
I  can  without  creating  too  much  disturbance,  and  defer  the  removal  of  the 
rest  until  the  irritation  caused  by  instrumentation  has  subsided.  It  is  in 
these  cases  that  the  current  through  the  lithotrite  comes  into  play  to  best 

advantage,  making  the  pieces  hunt  the 
instrument  instead  of  the  instrument 
hunting  the  pieces. 

Tlte  Results. — "  I  do  the  greater 
number  of  the  operations  on  my  otKce 
table — often  at  a  first  visit.  I  have 
been  using  my  lithotrite  sixteen  years ; 
have  ojierated  on  one  hundred  and 
twenty-one  cases.  There  have  been 
three  deaths  within  a  month  of  the 
time  of  operation.  An  autopsy  in  each 
leaves  no  doubt  that  the  practice  had 
nothing  to  do  with  the  fatal  results  in 
two  cases,  and  that  the  third  might 
possibly  have  been  saved  by  lithotomy. 
Many  of  the  cases  were  in  a  most  pitia- 
ble condition — old,  worn  with  pain, 
marked  degeneration  of  important  or- 
gans, kidneys,  liver,  and  heart." 
ill    I  II       II       I  I  Perineal    Lithotrity  with  Lithol- 

%J>  I  f  apaxv.  —  A    stone     mav    be    crushed 

through  an  opening  in  the  perinseum. 
Perineal  lithotrity  has  as  yet  been 
rarely  adopted  as  a  primary  method  of 
treatment,  but  rather  as  an  expedient 
to  facilitate  the  removal  of  a  stone  too 
large  to  be  extracted  through  the  in- 
cision made  for  the  purpose  of  a  sim- 
ple lithotomy.  It  has  been  advocated 
(perineal  litholapaxy)  as  a  substitute 
for  lithotomy  in  large  stones,  because 
the  crushing  and  the  use  of  the  wash- 
ing apparatus  can  be  substituted  for 
the  necessary  incision  through  the  deeper  parts.  Still,  the  withdrawal  of  an 
ordinary-sized  stone  can  hardly  compare  in  point  of  danger  to  the  repeated 
introduction  of  instruments  and  the  necessary  prolongation  of  the  operation 
of  crushing  through  an  open  wound,  especially  in  the  hands  of  the  inex- 
perienced. However,  it  is,  without  doubt,  an  expedient  which  should  be 
more  frequently  adopted,  particularly  for  the  removal  of  large  stones  through 
an  opening  too  small  to  admit  of  their  safe  withdrawal. 

Dolbeau  systematized  perineal  lithotrity  and  crushing  for  the  treatment 
of  large  stones. 


P;w»\\ 


Fig.  1372.— Dolbeau".s  dilator. 


OrEUATlUXS   UN    THE    UlilNAliV    BLADDER. 


11Y9 


Fig.  1373. — Dolbeau's  method,  first  step. 


The    Operation. — !Make    un    iiui.sion 
through    the    })erina'iim    as    in    inccliaii 
lithotomy  (pugo   119:i),  after  which  tlie 
dihitatiou    is   divided    into   three   steps, 
the  dihitor  of    Dolbeaii  being  employed 
(Fig.   137"-2).      The  first  step  consists  in 
the  dilatation  of  the  tissues  down  to  the 
groove   in   the    staff    (Fig.    1373)  ;    tJie 
sec07id.,  the  dilatation  of  the  tissues  nearly 
through  the  neck  of  the  bladder  (Fig. 
1374);  the  third,  the  withdrawal  of  the 
staff  and  the  carrying  of  the  dilator  suf- 
ficiently to  thoroughly  dilate  the  neck  of 
the  bladder  when  expanded  (Fig.  1375). 
The  dilatation  in  all  the  steps  must 
be  done  carefully  and  in  accordance  with 
the  resistance  encoun- 
tered.     The  prostate 
and  the  neck  of  the 
bladder  can  be  dilated 
one  inch  without  dan- 
ger.    After  it  is  com- 
pleted    a     lithoclast 
(Fig.  1376)  of  suitable  size  is  introduced  and  the  stone  fragmented,  after 
which  it  comes  away  with  the  urine.     A  small  reverse  current  (Fig.  1388)  of 

warm  aseptic  and  carbol- 
ized  water  thrown  into  the 
bladder  can  be  used  to 
wash  the  fragments  out. 
Dolbeau's  shield  (Fig.  1377) 
for  protection  of  the  soft 
parts  during  crushing 
should  be  employed,  espe- 
cially in  severe  and  pro- 
tracted cases. 

Ii  eg  in  aid  Harrison,  aft- 
er much  experience,  ex- 
presses the  belief  that  the 
introduction  through  the 
prostate  of  a  small  taj)er- 
ing  gorget  (Fig.  1314,  d) 
(Teale's,  Fig.  1314),  fol- 
lowed by  dilatation  with  the 
index  finger,  is  a  safer  and 
more   satisfactory   method 

Fig.  1374.-Dolbeau'.s   X        \  ""^^  "     °^  entrance  to  the  bladder 

method,  second  step.  ^*^— ^  ^^  this  oj^eration  than  the 


1180 


OPERATIVE   SUllGERY. 


use  of  the  Dolbeau  dilator,  as  the  hitter  is  liable  to  inflict  serious  injury. 
Also  he  advises  the  use  of  crushing  force})s  with  blades  resembling  those  of 
a  lithotrite,  with  a  cutting  rib  between  them,  and  the  handles  provided  with 
a  screw  for  strong  leverage  purposes.  The  fragments  are  removed  by  evacu- 
ating catheters  of  the  size  of  the  perineal  wound — about  the  size  of  the  index 
finger — and  directly  by  the  use  of  forceps. 

Harrison  regards  the  operation  favorably  for  the  following  reasons :  "  1. 
It  enables  the  operator  to  crush  and  evacuate  large  stones  in  a  short  space  of 
time.  2.  It  is  attended  with  very  little  risk  to  life  as  compared  with  other 
operations  where  cutting  is  done,  such  as  lateral  or  suprapubic  lithotomy, 
and  is  well  adapted  to  old  and  feeble  subjects.  3.  It  permits  the  operator 
to  wash  out  the  bladder  and  any  pouches  connected  with  it  more  effectually 
than  by  the  urethra,  as  the  route  is  shorter  and  the  evacuating  catheters  are 
of  much  larger  caliber.  4.  The 
surgeon  can  usually  ascertain, 
either  by  exploration  with  the 
fingers  or  by  introduction  of  the 
forceps  into  the  bladder,  that 
the  viscus  is  cleansed  of  all  de- 
bris. 5.  It  enables  the  surgeon 
to  deal  with  certain  forms  of 
prostatic  otttgrowth  and  obstruc- 
tion, complicated 
with  atony  of  the 
bladder,  in  such 
a  way  as  to  secure 
not  only  the  removal  of  the 
stone,  but  the  restor.ition  of  the 
function  of  micturition.  G.  By 
the  subsequent  introduction  and 
temporary  retention  of  a  soft- 
rubber  drainage  tube,  states  of  cystitis  due  to  retention  of  urine  in  pouches 
and  depressions  in  the  bladder  wall  are  either  entirely  cured  or  are  per- 
manently improved.  To  lock  up  unhealthy  ammoniacal  urine  in  a  bladder 
that  can  not  properly  empty  itself,  after  a  lithotrity,  is  to  court  the  forma- 
tion or  recurrence  of  phosphatic  stone.  Hence  it  is  well  suited  to  some 
cases  of  recurrent  calculus." 

He  regards  it  well  adapted  to  cases  of  stone  complicated  with  deep 
stricture,  as  then  both  can  be  treated  at  the  same  time.  It  lessens  the  risk 
of  the  performance  of  lithotrity  in  the  presence  of  a  permanently  damaged 
urethra. 

The  Besults. — The  results  are  eminently  satisfactory,  much  better  than 
are  secured  by  other  methods  in  similar  cases.  Harrison  reported  14  cases 
in  1894;  all  successful. 

Lithotrity  in  the  Female.— The  absence  of  the  prostate  body  and  the 
shorter  and  larger  urethra  of  the  female  combine  to  secure  a  more  complete 
emptying  of  the  bladder,  and  also  lessen  the  liability  to  the  formation  of  vesi- 


FiG.  1375. — Dolbuau's  iiietliocl,  third  step. 


((PKRATIOXS   OX    TIIK    LKINAKV    IJLADDlOlt. 


ILSl 


cal  calculi.  A  stone  iu  the  female  bladder  can  not  be  grasped  with  the 
same  facility  as  can  one  in  the  male,  owing  to  the  difference  in  the  normal 
shape  and  surroundings  of  the  blatldcr  and  to  the  {)atlu)logical  modifications 
to  which  its  cavity  is  subjected,  due  to  its  connections  with  the  uterus  and 
vagina,  and  the  physiological  and  pathological  variations  caused  by  child- 
bearing  and  its  sequels.  The  greater  liability  to  a  sacculated  base  requires 
that  the  instrument  be  reversed  more  frequently  than  in  the  sterner  sex. 


ro: 


Fig.  1376.— Goiilev's  lithoclasts, 


Because  of  the  presence  of  the  uterus,  the  posterior  wall  of  the  bladder  is 
more  irregular  and  flat  than  that  of  the  male,  and  the  fragments  do  not 
gravitate  to  the  same  situation  ;  instead,  they  are  found  lower  down  at  the 
vaginal  aspect,  and  require  that  the  lithotrite  be  held  almost  vertically  in 
order  to  grasp  them,  rather  than  at  the  angle  of  45°  as  in  the  male.  It  is 
sometimes  necessary  to  raise  the  vaginal  septum  with  the  finger  so  that  the 
stone  may  be  caught.     The  operation  can,  however,  be  readily  performed, 


1182 


OPERATIVE  SUEGEKY. 


and,  aside  from  the  variations  in  the  manoeuvres  necessary  to  catch  the  stone, 
differs  but  little  from  that  in  the  male. 

Evacuating  apparatus  can  be  satisfactorily  utilized  in  these  cases,  and 
should  be  employed  when  practicable.  A  short,  straight  evacuating  catheter 
is  the  best  for  use  in  these  cases.  Encysted  stones  and  large  hard  ones 
should  be  dealt  with  by  suprapubic  lithotomy. 

Lithotomy. — Lithotomy  is  the  operation  for  the  removal  of  stone  from 
the  bladder  by  cutting. 

The  accepted  varieties  of  perineal  incision  in  this  operation  are  the  lateral, 
median,  bilateral,  and  medio-bilateral  incisions.  The  suprapubic  incision, 
variously  modified,  is  now  in  common  use. 

The  Anatomical  Points. — The  periugeum  proper  is  a  triangular-shaped 
space,  the  apex  corresponding  to  the  center  of  the  pubic  arch,  the  base  to  a 
line  drawn  transversely  between  the  anterior  portions  of  the  tuber  ischii,  and 
the  sides  limited  by  the  rami  of  the  pubes  and  ischium.     In  the  adult  male 

the  base  of  the  triangle  is 
from  two  to  three  and  a 
half  inches  in  breadth,  and 
the  sides  from  three  to  three 
and  a  half  inches  in  length. 
The  dimensions  of  the  base 
are  of  especial  interest,  since 
the  narrower  it  is  the  less 
oblique  lateral  incisions  can 
be  made.  The  perina?um  is 
divided  into  two  equal  parts 
by  the  median  rhaphe,  the 
anatomy  of  each  being  simi- 
lar. The  left  half  is  the  more  important,  on  account  of  its  relation  to  lateral 
lithotomy.  The  bulb  of  the  urethra  and  the  central  fibrous  point  are  on  the 
median  line,  the  latter  being  located  about  half  an  inch  in  front  of  the  anus 
and  just  behind  the  bulb.  The  internal  pudic  artery  runs  along  the  inner  sur- 
face of  the  tuber  ischium  (Figs.  180, 1331,  and  1336),  giving  off  hemorrhoidal 
branches  and  farther  along  the  superficial  perineal  branches  and  artery  of  the 
bulb.  The  relation  of  these  several  vessels  to  the  cutting  operation  for  stone 
should  be  carefully  considered  before  operation  is  begun.  The  fascia  of  the 
perinaium  is  of  great  anatomical  importance  in  connection  with  the  course 
taken  by  extravasated  urine  (Fig.  1378).  If  the  extravasation  happen  between 
the  anterior  and  posterior  layers  (a,  a)  of  the  triangular  ligament  the  mem- 
branous urethra  is  at  fault,  and  the  extravasation  is  limited  at  first  to  the  deep 
triangular  space  ;  if  the  fluid  lie  just  in  front  of  this  ligament,  it  promptly 
extends  over  the  scrotum  and  penis  on  to  the  abdomen,  but  is  limited  behind 
and  at  the  sides  to  the  base  and  borders  of  the  perineum  ;  it  does  not  extend 
on  to  the  thighs.  If  tlie  fluid  lie  in  front  of  the  superficial  perineal  fascia,  it 
then  extends  beneath  the  superficial  fascia  of  the  periupeum  in  all  directions. 
Of  course,  after  suppuration  occurs  the  distinctive  importance  of  the  fascial 
arrangement  promptly  disappears.      In  a  thin  perineum   the  base  of  the 


Fig.  1377.— Dolbeau's  shield  to  protect  the  walls  of 
the  wound  during  crushing. 


Ol'KUATIOXS   OX    TllK    UKINAUV    I5I.A  DDKK. 


1183 


triiUi^uhir  li^unu'iit  van  be  fulL  on  (k'l'j)  prussuru  jii.st  in  front  of  the  aims. 
This  is  iiu  important  perineal   hmdmai-k,  us  the  inenibrunoiis  urethra  lies 


Fig.  1-378. — Deep  surgical  anatomy  of  periniiMiin.  bladder,  etc.  a,  a.  Space  between  the 
superficial  and  deep  layers  of  triangular  ligament,  b.  Space  posterior  to  deep  layer 
of  triangular  ligament,  continuous  with  Retzius's  space,  c.  Cowper's  gland,  e.  Ket- 
zius's  space,     d.  ^Membranous  portion  of  urethra. 

about  three  quarters  of  an  inch  above  this  point,  and  about  the  same  distance 
below  the  subpubic  ligament,  as  it  passes  between  the  layers  of  the  triangular 
ligament  (Fig.  1379).  The  prostate 
body  is  placed  in  front  of  the  blad- 
der and  around  the  beginning  of  the 
urethra.  The  shape,  dimensions,  spe- 
cial characteristics,  and  anatomical  re- 
lation of  it  to  the  bladder  and  urethra 
exercise  an  important  influence  on 
the  surgical  technique  of  ])erineal  ap- 
proach to  the  bladder,  and  they  ought 
to  be  carefully  studied  in  an  accred- 
ited anatomical  work  before  attempt- 
ing operation.  The  bladder  is  about 
two  inches  and  a  half  to  three  inches 
from  the  surface  of  the  perinaeum,  Avitli  the  patient  in  the  lithotomy 
position. 


Fig.  1379. — The  anterior  layer  of  triangu- 
lar ligament,  showing  opening  for 
membranous  portion  of  urethra. 


1184 


OPERATIVE  SURGERY. 


Lateral  Lithotomy. — Lateml  lithotomy  is  employed  when  the  stone  is 
too  large  to  be  easily  removed  through  the  dilated  prostate.  The  special 
instruments  are  a  stalf  of  suitable  size,  with  the  proper  curve  and  a  deep 
groove  upon  its  convexity  which  approaches  the  right  lateral  aspect  as 
it  nears  the  extremity  of  the  beak  (Fig.  1380) ;  a  bistoury,  with  a  stout  blade 
and  handle,  a  solid  (Fig.  1:381)  shank,  a  sharp  point,  and  a  cutting  edge  of 
about  two  inches  in  length  ;  a  probe-pointed  knife — the  one  devised  by 
Blizard  (Fig.  1382)  being  the  best — and,  if  the  perinaeum  be  deep,  due  to 
obesity  or  other  cause,  the  gorget  may  be  selected  (Fig.  1383) ;  a  combined 
scoop  and  conductor  is  serviceable  (Fig.  1384) ;  forceps  of  various  sizes  and 
shapes  to  seize  the  stone,  one  of  which  should  be  arranged  with  crossed 
handles  to  avoid  stretching  the  parts  about  the  neck  of  the  bladder  when 
the  stone  is  grasped  (Figs.  1385  and  1386).  It  is  well  to  be  provided  with  a 
small  lithoclast  for  the  purpose  of  breaking  stones  too  large  to  be  extracted 


81. — Dupuytren  s  kiiil'f. 


Fig.  1383.— Blizard's  knife. 


Fig.  1383.— Blunt  gorget. 


Fig.  1384. — Scoop  and  conductor. 


with  safety,  a  scoop  to  dislodge  the  remaining  fragments  of  stone  (Fig.  1387), 
and  a  syringe  to  wash  from  the  bladder  any  small  fragments  that  may  remain 


OPERATIONS   ON    TIIK    IKINAIJ^'    l;l.AI)l)i;i{. 


118f 


(Fig.  loMS).  Davidson's  syringe  can  be  used,  but  is  less  siitisfuc;t<jr}'  than  one 
designed  for  the  purpose.  The  cliemise  or  shirted  and  tiie  air-bag  cannuhi 
(Figs.  loS!),  i;{'.Hi,  and  l.")i)l)  are  useful  to  control  luernorrluige.  At  least  five 
assistants  should  be  present.  To  one  of  these  the  stall  should 
be  intrusted  ;  the  lower  limbs  may  be  controlled  by  two  others, 
either  with  or  without  the  limbs  being  coufined  by  the  anklets 
(Fig.  lo'.c.*).  The  hands  and  feet  may  be  bandaged  together 
satisfactorily  for  the  purpose.  Of  the  remaining  assistants,  one 
should  attend  the  instruments  and  the  other  the  sponges,  etc. 


Fig.  laS.^i.— Straight     Fig.  13SG.— Curved 
forceps.  lithotomy  forceps. 


Fig.  1;}87.— Dol-     Fig.   i:iS8.— Van    Buren's 
beau's  lithoclast.  debris  syringe. 


The  more  modern  device  for  separating  the  lower  limbs  and  exposing  the 
perinjeum  will  be  found  of  great  service  (Fig.  1393).  Forcipressure,  retract- 
ors, ligatures,  wipers,  and  drainage  tubes,  sliould  be  at  hand. 

The  rreliminarii  Steps  to  the  Operation. — Rest  in  bed  for  two  or  three 
days  before  operation,  or,  at  the  least,  long  enough  to  ascertain  the  condition 
of  the  kidneys,  r._  indicated  by  the  amount  and  character  of  the  urine,  is  very 
important.  The  cleansing  of  the  bladder  with  an  aseptic  lluid  should  be 
practiced  during  this  time  if  the  urine  be  offensive  or  much  vesical  irritation 
be  present. 

Shave  and  disinfect  the  parts,  empty  the  rectum  with  an  enema,  admin- 
ister an  anaesthetic,  draw  tlie  patient  down  to  the  edge  of  the  table,  and  con- 
trol the  lower  extremities  by  bandaging  them  to  the  upper,  or  give  each  one 
in  charge  of  an  assistant. 


1180 


OPERATIVE  SURGERY. 


The  stall  is  introduced  and  the  stone  found — a  fact  that  should  be  veri- 
fied by  others  present.  If  the  stone  be  not  detected  the  staff  should  be 
withdrawn,  and  its  presence  and  location  determined  by 
the  searcher.  These  points  must  likewise  be  confirmed 
by  others.  If  the  stone  be  not  found  at  all,  the  opera- 
tion must  be  deferred. 


Fig.  1389.— Chemise 
cannula. 


Fig. 


1390.— Chemise 
catheter. 


Fig.  1391. — Browne's  air  tampon  and 
cannula. 


The  principal  assistant,  who  holds  the  staff,  should  satisfy  himself  that 
the  sound  is  in  contact  with  the  stone,  although  it  is  not  necessary  that  it  be 
pressed  against  it  during  the  operation.     The  holder  of  the  staff  should  stand 

at  the  patient's  left  and 
hug  it  firmly  beneath  the 
pubes  with  the  right  hand, 
while  the  integument  of 
the  periiiffium  is  made 
tense  by  drawing  up  the 
scrotum  with  the  left. 
The  convexity  of  the  staff 
should  be  easily  felt  in  the 
perinffium.  If  the  peri- 
nfeum  be  thin  the  groove 
may  be  distinctly  defined 
with  the  finger.  Some  sur- 
geons have  advised  that  the 
staff  be  pressed  against  the 
peringenm,  instead  of  the  pubes,  that  the  outline  may  be  the  better  defined. 
However,  it  is  a  matter  of  little  importance  which  course  is  taken,  as  long  as 


Fig.  1392. — Pritchard's  anklets  and  wristlets. 


OPERATIONS   OX  THE   UKINAKV    I'.l.ADDKlC. 


1187 


tiie  pubes  are  huggetl  by  the  instrument  while  the  incision  is  being  made 
into  tiie  bladder.  The  surgeon  should  sit  upon  a  low  stool,  and,  before 
beginning  the  incision,  carefully  map  out  the  location  of  the  bulb  and  tlie 
point  where  the  incision  is  to  begin,  also  determine  the  outlines  of  the  rami 
and  tuber  ischii.  He  then  introduces  the  index  linger  of  the  left  hand  into 
the  rectum,  locates  the  apex  of  the  prostate,  and  deterniines  its  relations  to 
the  sound.  The  tinger  is  withdrawn,  thoroughly  cleansed,  and  the  groove 
in  the  staff  again  located. 

The  Operation. — The  incision  is  commenced  a  little  to  the  left  (one  third 
of  an  inch)  of  the  median  rhaphe,  from  an  inch  and  a  quarter  to  an  inch  and 
3k  half  in  front  of  the  anus  (Fig.  1402,  b).  The  point  of  the  knife  is  made  to 
enter  the  groove  at  the  second  or  third  cut,  being  guided  there  by  the  nail 
of  the  index  linger  of  the  left  hand.    The  perineal  incision  is  made  obliquely 


Fig.  1393. — Clover's  cruteh  to  hold  the  legs  (Fig.  1402),  with  strap  to  go  over  the 

shoulders. 

•downward  from  three  to  three  and  a  half  inches  in  length,  midway  heticeen 
the  hiber  isch  ii  and  the  verge  of  the  anus.  It  is  deep  above  and  should  be  shal- 
low below.  The  urethra  is  then  freely  opened,  and  the  probe- pointed  bistoury 
substituted  for  the  scalpel ;  or  the  blunt  extremity  of  the  Blizard  (Fig.  1382) 
or  another  suitable  knife  is  engaged  in  the  groove,  when  the  surgeon,  taking 
the  handle  of  the  staff  in  the  left  hand,  draws  it  downward  somewhat,  and 
then,  holding  it  firmly,  carries  the  point  of  the  knife  along  the  groove  toward 
the  bladder  in  the  line  of  the  perineal  incision,  depressing  its  handle  slightly 
to  correspond  to  the  curve  of  the  staff.  As  soon  as  the  end  of  the  knife  is 
stopped  by  the  termination  of  the  end  of  the  groove  in  the  staff  its  handle 
is  depressed,  the  edge  turned  outward  still  more,  and  the  deep  tissues  sev- 
ered from  within  outward  by  its  withdrawal,  care  being  taken  to  make 
the  incision  through  the  prostate  more  horizontal  than  that  of  the  perinaeum 
81 


1188 


OPERATIVE  SURGERY. 


(Fig.  1394).     The  flow  of  urine  wliich  follows  assures  the  operator  of  suc- 
cessful entrance  to  the  bladder.' 

It  is  recommended  to  press  the  point  of  the  scalpel  firmly  against  the 
groove  in  the  staff  with  the  right  hand,  seize  the  stalf  with  the  left,  depress 
the  handle  of  the  staff  and  the  knife  at  the  same  time,  to  the  same  extent,, 
and  thus  convert  them  for  the  moment  into  one  instrument  which  is  pushed 
into  the  bladder.     This  plan   is  often  practiced,  and  when  carefully  done 

will  prevent  the  escape  of  the  point 
of  the  knife  from  the  groove.  It  is 
more  difficult,  however,  to  properly 
lateralize  the  knife  in  its  passage 
through  the  prostate  in  this  than  by 
the  former  method  ;  besides,  it  is  a 
less  elegant  act.  The  asepticized  in- 
dex finger  of  the  left  hand  is  now 
passed  carefully  into  the  bladder  along 
the  staff,  which  is  then  withdrawn. 
The  neck  of  the  bladder  is  dilated  by 
tiie  finger,  the  stone  reached,  and  its 
diameter  estimated,  if  it  has  not  been 
done  before.  The  closed  forceps  (Fig. 
1385  or  1386)  is  now  passed  into  the 
bladder  along  the  finger  as  it  is  with- 
drawn, and  the  stone  carefully  sought 
for  and  grasped  in  the  short  diameter^ 
if  possible.  If  one  blade  of  the  opened 
forceps  be  pressed  upon  the  floor  of 
the  bladder,  the  stone  will  often  roll 
promptly  within  its  grasp.  However  this  may  be,  unusual  caution  must  be 
employed  in  the  manipulation,  so  as  not  to  bruise  the  contracted  walls  of 
the  viscus.  If  the  stone  be  grasped  in  its  long  axis  it  should  be  dropped 
and  the  position  corrected  by  the  finger  carried  into  the  bladder.  The 
change  in  the  direction  of  the  long  axis  of  the  stone  may  sometimes  be  ac- 
complished by  carrying  two  fingers  into  the  rectum,  separating  and  pressing 
them  upward  against  the  bladder,  thereby  compressing  its  sides  and  creating^ 
a  furrow  running  antero-posteriorly  into  which  the  stone  will  drop  corre- 
spondingly. When  properly  grasped  the  stone  is  withdrawn  by  steady  trac- 
tion made  in  the  axis  of  the  floor  of  the  pelvis  and  in  the  line  of  the  perineal 
incision.  As  soon  as  the  calculus  is  removed,  its  surface  is  examined  for 
facets,  which  will  indicate  the  presence  of  one  or  more  calculi  still  in  the 
bladder.  Having  removed  the  calculus,  irrigate  the  bladder  with  warm 
aseptic  fluid  to  remove  all  blood  clots  and  whatever  detritus  may  be  present. 
If  there  be  earthy  matter  in  the  bladder  it  may  be  necessary  that  it  be 
removed  with  a  scoop. 

Lateral  Lithotomy  in  Children. — Lateral  lithotomy  in  children  is  modi- 
fied somewhat  on  account  of  their  relatively  different  normal  anatomical 
state. 


Fig.  1394. 


-Lateral  incision  of  prostate  and 
perinjeum. 


OPERATIONS   ON   THE    UUINARV    BLADDER.  il,s9 

71ie  Anatomical  Points. — The  pelvis  is  small ;  the  bladder  is  high  in  the 
pelvic  cavity,  freely  movable  and  insecurely  fixed  ;  the  urethra  is  small  and 
thin,  hence  the  more  readily  torn;  the  prostate  is  undeveloped  and  the  neck 
of  the  bladder  correspondingly  exposed  to  division,  which,  if  too  extended, 
may  involve  the  pelvic  fascia.  However,  the  perinaeuni  is  thin  and  the  bulb 
diminutive,  therefore  the  staff  can  be  easily  felt.  'J'he  high  position  of  the 
bladiler  enables  the  surgeon  to  control  it  well  by  abdominal  and  rectal 
palpation. 

The  Precdvtiotts. — Note  that  the  instruments  are  of  proper  size  and  that 
gentleness  of  manipulation  be  practiced.  A  too  forcible  effort  at  introduc- 
tion of  the  fingers  may  push  the  bladder  upward  in  front  of  them  or  tear  the 
prostate.  A  forcible  dilatation  of  the  neck  of  the  bladder  is  therefore  to  be 
avoided,  and  relatively  free  incision  made  instead. 

The  operation  in  the  child  differs  in  no  important  regard  from  that  in 
the  adult,  except  that  the  incision  into  the  bladder  is  made  relatively  freer 
and  the  vesical  wound  is  dilated  carefully  with  dressing  forceps  instead  of 
with  the  fingers,  at  the  outset.  If  greater  capacity  be  needed  the  forceps 
are  removed  and  a  small  probe  is  introduced  as  a  guide  to  the  finger,  which 
is  then  carefully  insinuated  along  the  probe  into  the  bladder.  First  the 
little,  then  the  index  finger  can  be  introduced  if  required.  The  stone  is 
removed  in  the  usual  manner  with  forceps  or  a  scoop,  aided  by  the  finger  in 
the  bladder  or  rectum. 

Tlie  General  Precautions. — In  lithotomy  the  incision  should  be  carefully 
laid  out  and  cautiously  made  to  avoid  cutting  the  bulb  and  its  artery  above, 
or  the  rectum  and  internal  pudic  below.  The  point  of  the  cutting  instrument 
must  be  surely  lodged  and  kept  in  the  groove  of  the  staff,  or  it  will  go  astray, 
doing  great  damage  and  misleading  the  surgeon.  The  handle  of  the  knife 
should  be  depressed  as  the  point  moves  forward  in  the  groove,  or  the  point  will 
leave  the  staff.  If  the  handle  be  depressed  too  much,  the  point  of  the  knife 
will  be  fixed  in  the  groove  and  further  advance  prevented  until  the  direction 
is  rectified.  If  the  staff  enter  a  false  passage  unnoticed  the  surgeon  is  misled, 
the  incision  misplaced,  and  perhaps  irretrievable  injury  done.  The  careless 
holding  of  the  staff  often  perplexes  and  may  confuse  and  mislead  the  oper- 
ator. The  staff  should  not  be  withdrawn  until  the  finger  or  a  probe  have 
been  passed  along  the  groove  into  the  bladder,  otherwise  the  lines  of  incision 
may  be  lost  and  much  difificulty  experienced  and  care  required  to  find  it 
again.  If  the  incision  be  too  small  the  tissues  w^ill  be  torn  by  the  extraction 
of  the  stone ;  room  can  be  gained  by  dilatation  or  by  repeated  incisions  made 
in  the  line  of  the  first  one,  or  at  the  opposite  side.  If  the  incision  be  made 
too  far  posteriorly  the  ejaculatory  ducts  will  be  cut.  A  too  free  incision  of 
the  neck  of  the  bladder  will  cause  urinary  infiltration  of  the  pelvic  fascia. 
Too  great  traction  on  a  stone  will  tear  the  neck  of  the  bladder,  perhaps 
beyond  the  limits  of  the  prostate,  causing  infiltration  and  sepsis.  A  lateral 
incision  of  the  neck  of  the  bladder  in  the  adult  should  be  limited  to  the 
extent  of  the  prostate  (three  quarters  of  an  inch). 

The  General  Remarks. — In  lithotomy  if  the  stone  be  encysted  it  is  very 
difficult  and  often  impracticable  to  remove  it.     It  may  be  possible  to  grasp 


1190 


OPERATIVE  SURGERY. 


an  exposed  portion  with  forceps  with  or  without  division  of  tlic  confining 
structure,  and  in  either  instance  great  care  and  judgment  must  be  exercised. 
An  irregular  contraction  of  the  bladder  may  cause  entanglement  of  a  stone. 
But  pressure  u})on  tlie  fundus,  supplemented  with  digital  touch  and  the 
employment  of  large  forceps,  will  meet  the  contingency.  Vigorous  traction 
on  the  short  axis  of  a  long  stone  pulls  the  bladder  downward  so  as  to  expose 
the  prostate  at  the  perineal  wound  if  continued.  Lateral  movements  with 
traction,  when  slowly  made,  will  facilitate  the  removal  of  a  calculus  without 
contributive  danger.  If  a  stone  be  too  large  for  safe  removal  it  should  be 
crushed  and  removed  piecemeal. 

The  Complications. — The  complications  can  be  rationally  divided  into 
the  concomitant  and  consequent  varieties. 

A  deep  perinteuni  due  to  corpulency,  enlargement  of  the  prostate,  the 
presence  of  tumors  in  the  bladder,  and  post-prostatic  encystment  of  the 
stone,  preventing  the  grasping  of  the  calculus,  are  not  infrequent  concomi- 
tant complications. 

Among  the  consequent  co^nplications  are  wounding  of  the  bulb,  the  rec- 
tum, or  the  bladder.  The  latter  viscus  may  be  severely  wounded  by  punc- 
ture with  the  staff,  the  slipping  of  the  knife  from  the  groove,  etc.  Lapa- 
rotomy and  closure  of  the  wound  should  be  promptly  practiced  in  those 


cases.  If  the  incision  be  carried  too  far  inward  or  outward  the  rectum  or 
the  pudic  artery  may  be  cut  respectively,  and  if  begun  too  far  from  the 
anus  or  at  the  median  line  the  bulb  will  suffer.  If  the  penis  be  drawn  for- 
ward on  the  staff,  and  the  staff  be  raised  against  the  pubic  arch  as  the 
urethra  is  being  opened  and  the  incision  extended,  the  bulb  is  drawn  away 
from  the  course  of  the  knife.  Breaking  of  the  stone  seems  a  trivial  compli- 
cation, but  may  be  very  annoying  before  the  fragments  are  all  removed. 
The  inability  to  find  the  stone  after  making  the  incision  is  perplexing,  which 
may  depend  on  a  false  passage,  a  hidden  calculus  or  its  unobserved  escape 
with  the  first  gush  of  urine,  or  possibly  on  a  mistaken  diagnosis.  Inconti- 
nence and  retention  sometimes  occur.  Hfemorrhage  at  the  time,  or  shortly 
after  the  operation,  is  a  troublesome  and  sometimes  fatal  complication.  If 
arterial  hnemorrhage  occur,  catch  and  tie  the  bleeding  point  if  practicable  ; 
the  bleeding  may  be  checked  by  ice  pressure  or  by  the  use  of  a  hot-water-bag 
tampon ;  if  these  be  inadequate  for  the  purpose,  forcipressure  may  be  applied 
to  the  bleeding  point  and  allowed  to  remain  for  twenty-four  hours.  The 
tying  in  of  a  tenaculum  or  the  use  of  acupressure  may  be  feasible.     Venous 


OPEKA'I'IONS   (>\    'I'lIK    riilXAltV    BI.AI)l)i:i{. 


111)1 


ha?morrhago  o;in  he  coiitrolleil  by  the  clieiuise  catheter  (Figs.  liJOO  and  13'Jl), 
tlie  air-l)a<x  taiiiiHui,  or  by  some  other  similar  expedient.  Prostatic  phlebitis 
followed  by  t  himubosis  and  sepsis  sometimes  follow,  either  originating  from 
the  [)rimary  wound  or  cansed  by  the  steps  essential  to  the  arrest  of  severe, 
deep-seated  ha'iiiorrhage.  Sup- 
pression of  urine  due  to  kidney 
disease  is  a  danger  not  to  be 
disregarded. 

While  the  preceding  tech- 
nique of  the  operation  is  that 
usually  employed,  still  there 
are  instrumental  moditications 
which,  in  the  opinion  of  some, 
may  lessen  the  dangers  of  the 
operation  in  inexperienced 
hands.  Tiie  instrument  de- 
vised some  years  ago  by  Smith, 
of  Baltimore,  and  suc(;essfully 
employed  by  him  and  others 
(Fig.  1395)  is  worthy  of  men- 
tion. It  consists  of  a  rectan- 
gular staff  with  a  well-rounded 
angle,  deeply  grooved  on  its 
hoi-izontal  portion,  and  pro- 
vided with  an  indicator  at- 
tached to  the  shaft  by  means 
of  a  hinge.  The  indicator  is 
likewise  rectangular,  and  termi- 
nates in  a  lance-shaped  blade. 
The  indicator  can  be  adjusted 
by  sliding  it  up  and  down  the 
staff ;  or  various  sizes  of  the 
instrument  may  be  employed 
to  meet  individual  differences. 
The  staff  is  introduced  and 
held  by  an  assistant  in  the  usual 
manner,  and  the  cutting  extremity  of  the  indicator  is  applied  to  the 
median  line  and  pushed  through  the  tissues  until  it  lodges  in  the  groove 
of  the  staff.  The  probe-pointed  gorget  is  then  j)assed  into  the  groove  and 
lodged  in  the  channel  on  the  staff,  along  which  a  cut  is  made  into  the  blad- 
der. A  probe-pointed  bistoury  may  be  substituted  for  the  gorget.  The  vse 
of  the  douhle  and  single  lithotomes  (Figs.  1396  and  1397)  were  advocated 
formerly  more  frequently  than  at  the  present  time.  But  then  as  now,  how- 
ever, their  advocates  were  small  in  number  as  compared  with  the  adherents 
of  the  use  of  the  scalpel  and  grooved  staff. 

The  After-treatment. — After  the  operation  place  the  patient  in  bed  with 
a  rubber  cloth   beneath  the  hips,  separated  from  the  body  by  cloths  and 


iM\r 


r> 


i^ 


Fio.  139G.— Dupuytren's     Fig.  1897.— Hutchinson's 
double  lithotome.  single  lithotome. 


1192 


OPERATIVE   SURGERY. 


sponges,  to  collect  the  urine  and  indicate  the  occurrence  of  haemorrhage. 
The  temporary  introduction  of  a  catheter  or  drainage  tube  into  the  bladder 
through  the  wound  in  the  perina^um  is  practiced  often,  especially  if  the 
patient  has  suffered  from  cystitis  with  infected  urine.  Under  these  circum- 
stances the  tube  should  not  be  omitted  for  three  or  four  days,  and  even 
longer  if  the  discharge  be  offensive  or  a  tendency  to  retention  be  present. 
If  the  tube  become  blocked  the  obstruction  should  be  removed  by  a  probe, 
an  aseptic  feather,  or  a  stream  of  water,  and  perhaps  be  removed  entirely  and 
cleansed.  If  a  long  silver  probe  be  carried  through  the  tube  and  allowed  to 
remain,  after  removal  it  will  be  of  great  service  in  returning  the  tube  to  the 
former  position.  Give  light  and  stimulating  diet,  alkaline  drinks,  and  treat 
all  sequelte  on  general  principles. 

The  Results. — The  rate  of  mortality  varies  from  6  to  10  per  cent. 


Fig.  1398.— Little's  lithotomy 
staff. 


Fig.  1399.— Mtirkoe's 
staff. 


Fig.  1400.— The  rectan- 
gular staff. 


Median  Lithotomy. — Median  lithotomy  is  applicable  to  cases  having  one 
or  more  small  stones  half  an  inch  or  so  in  diameter,  and  in  advancing  pu- 
berty for  prostatic  calculi  and  for  small  calctili  with  offensive  cystitis.     In 


OIMORA'I'IONS   OX    THK    URINARY    BLADDKR.  11«),3 

this  method  there  is  less  (hinger  from  ha'morrhii<,'(!,  much  better  control  of 
the  urine  from  the  lirst,  tmd  the  wound  heals  rapidly.  If  the  stone  be 
larger  tluin  is  anticipated, 
the  temptation  to  use  un- 
due violence  during  the  ^^f  Fio.  1401.— Little's  director, 
extraction  is  great.  It  is 
claimed  that  this  method 
may  be  followed  by  stric- 
ture of  the  urethra,  and  also  that  the  mouths  of  the  seminal  ducts  are  more 
likely  to  be  injured  by  extraction  of  tlie  stone  than  in  the  other  methods. 
However,  the  exposure  of  the  ducts  to  injury  by  cutting  is  eliminated  in 
this  method. 

The  general  precautions  to  be  employed  in  all  forms  of  lithotomy  are 
mentioned  fully  in  connection  with  the  lateral  operation  (page  1844  et  seq.). 
'Ihe  instruments  are  the  statf,  director,  and  knife.  The  staffs  vary  some- 
what in  the  shape  and  depth  of  the  grooves.  The  ones  devised  by  Little 
(Fig.  1398)  and  Markoe  (Fig.  1399)  leave  nothing  to  be  desired.  The  rec- 
tangular variety  (Fig.  1400)  can  be  used  in  lieu  of  the  curved  one,  although 
it  has  been  infrequently  employed  in  this  country.  The  director  devised  by 
Little  is  an  admirable  instrument  (Fig.  1401),  but  is  by  no  means  alone 
essential  to  successful  operation.  A  stout,  straight,  sharp  bistoury,  double- 
•edged  at  the  point  for  making  the  perineal  incision,  makes  the  especial  outfit 
complete. 

Tlte  Operation. — Confine  the  patient  in  the  lithotomy  position  (Fig. 
1402)  ;  introduce  the  staff,  placing  the  end  of  the  beak  in  contact  with  the 
stone ;  pass  the  left  index  finger  into  the  rectum  and  locate  the  apex  of 
the  prostate  just  where  the  staff  enters  it ;  introduce  the  point  of  the  knife 
into  the  median  line  of  the  periuajum  half  an  inch  in  front  of  the  anus  (a), 
with  the  long  cutting  edge  uppermost,  and  push  it  carefully  upward  to 
the  apex  of  the  prostate,  guided  by  the  finger  in  the  rectum,  into  the 
groove  of  the  staff.  The  knife  is  advanced  sufficiently  toward  the  bladder 
to  nick  the  apex  of  the  prostate,  after  which  it  is  carried  forward  to  divide 
the  membranous  portion  of  the  urethra.  The  external  incision  should  be 
from  an  inch  and  a  quarter  to  an  inch  and  a  half  in  length,  care  being  taken 
to  avoid  the  bulb  of  the  urethra.  The  director  is  then  passed  into  the  blad- 
der along  the  staff,  and  the  neck  of  the  bladder  moderately  dilated  by  sepa- 
rating the  two  from  each  other.  The  staff  is  then  withdrawn,  and  the  asep- 
ticized index  finger  of  the  left  hand  is  carried  through  the  neck  of  the 
bladder  along  the  director  with  a  semirotary  motion  to  complete  the  dilata- 
tion. The  forceps  is  then  introduced,  the  stone  caught  at  its  short  diame- 
ter, and  removed  by  steady,  gradual  traction,  which  may  be  accompanied  by 
rocking  movements,  but  never  by  a  rotation  of  the  instrument  on  its  long 
axis  while  grasping  the  stone. 

Various  instruments  have  been  devised  to  dilate  the  prostate  in  this  and 
other  methods  calling  for  the  procedure,  all  of  which  when  carefully 
employed  answer  the  purpose  well,  but  are  by  no  means  essential  to  a  safe 
performance  of  the  operation.     After  the  removal  of  the  stone,  arrest  haem- 


1194 


OPERATIVE  SURGERY. 


orrliage,  seek  for  any  remaining  calculi,  and  otherwise  treat  the  patient  as 
indicated  in  the  lateral  operation. 

The  Remarks. — The  small  size  of  the  perineal  opening  in  children  may 
interfere  with  the  proper  removal  of  the  calculus.     Care  in  the  avoidance  of 


Fig.  1402. — Lines  of  incision  in  perineal  lithotomy,  showing  Clover's  apparatus  applied. 
a.  Incision  in  median  lithotomy,  b.  Incision  in  lateral  lithotomy,  c.  Incision  in 
bilateral  lithotomy. 

injury  of  the  bulb  and  the  rectum  is  especially  needful  in  this  operation. 
Inasmuch  as  the  operation  is  suited  only  for  the  removal  of  small  stones, 
which  usually  can  be  better  done  by  lithotrity,  the  procedure  is  now^  com- 
paratively rarely  practiced. 

The  Results. — The  death  rate  is  from  4  to  8  per  cent. 

The  Bilateral  Lithotomy. — The  preliminary  preparations,  the  precautions, 
and  general  arrangements  in  this  are  similar  to  those  necessarv  in  the  other 
methods.  The  special  instruments  are  the  grooved  staff  and  the  bisector, 
so  intimately  associated  with  the  name  of  the  late  James  K.  Wood  (Fig. 
1403),  or  the  lithotorae  of  Dupuytren  or  Briggs  (Figs.  139G  and  1404). 

Tlie  Operation. — Make  a  semilunar  incision  across  the  perin^eum,  three 
fourths  of  an  inch  in  front  of  the  anus,  beginning  midway  between  the  anus 
and  the  tuberosity  on  the  right  side,  and  terminating  at  a  similar  point  on  the 
opposite  side  (Fig.  1402,  c).  The  convexity  of  the  cut  is  directed  forward. 
The  several  tissues  are  divided  down  to  the  membranous  urethra,  which  is 
opened,  and  the  beak  of  the  instrument  is  inserted  in  such  a  manner  as  to 
cause  the  beveled  edges  of  the  bisector  to  be  uppermost.  After  moving  the 
beak  backward  and  forward,  to  be  certain  that  it  is  well  lodged  in  the 
groove,  it  is  then  firmly  pressed  against  the  groove  of  the  staff,  and,  with  the 


OPKUATIONS  ON  TiiK  rin\AK\    i;i,.\ i)i)i;i:. 


111>5 


stiifT  held  firmly,  it  ia  carried  into  the  bludder.  The  stiilT  aiul  cutting  instru- 
ment may  be,  practically,  converted  into  a  single  instrument  by  pressing 
them  firmly  together  and  carrying  them  inward  at  the  same  time,  being 
careful  to  (k'press  simultaneously  the  handle  of  eacrh  to  the  same  degree. 

The  Precautions. — The  cutting  instrument  may  be  carried  beliind  the 
bladder  if  any  tissues  exist  between  the  groove  and  its  probe-pointed  extrem- 
ity, or  its  handle  be  not  depressed  so  as  to  keep  the  beak  in  the  groove  of 
the  staff.  The  anterior  wall  of  the  rectum  may 
be  cut  while  nuiking  the  cresceiitic  incision,  if 
directed  too  much  downward.  'J'his  accident 
can  be  avoided  by  inserting  the  index  finger  of 
the  left  hand  into  the  bowel  when  the  primary 
incision  is  being  made,  and  drawing  the  anterior 
wall  backward  while  the  cut  is  being  completed. 

The  results  obtained  by  this  method  in  the 
hands  of  Dr.  Wood  were  equal  to,  if  not  better 
than,  those  previously  given  in  connection  with 
the  other  methods  of  cutting  for  stone, 

Nelaton's  Modification. — Nelaton  modified 
the  first  step  of  the  bilateral  method  with  the 
view  of  lessening  the  danger  of  cutting  the  bulb 
and  the  wall  of  the  rectum.  He  introduced  the 
left  index  finger  into  the  rectum,  placed  the 
end  of  it  against  the  apex  of  the  prostate,  and 
steadied  the  anterior  border  of  the  anus  with 
the  thumb  of  the  same  hand.  He  then  nuide 
a  semilunar  incision  in  front  of  the  anus,  the 
extremities  of  which  were  four  fifths  of  an  inch 
from  the  anus  at  either  side,  and  the  greatest 
convexity  three  fifths  of  an  inch  from  it.  The 
dissection  was  continued,  layer  by  layer — the 
wall  of  the  rectum  and  the  bulb  being  care- 
fully avoided — until  the  membranous  urethra 
was  reached  and  opened,  and  the  cutting  instru- 
ment introduced.  The  same  object  was  accom- 
plished through  a  transverse  incision  an  inch 
and  a  quarter  in  length,  with  its  center  located 
three  fifths  of  an  inch  in  front  of  the  anus. 

The  Medio-lateral  Lithotomy. — This  method  was  introduced  by  Buchanan., 
of  Glasgow. 

The  necessary  instruments  are  a  rectangular  staff  with  a  broad  groove  at 
the  left  side,  and  a  narrow,  straight  knife  with  a  long  cutting  edge.  The 
staff  is  introduced,  and  the  prominent  staff  angle  adjusted  to  correspond 
to  the  muco-cutaneous  junction  on  the  anterior  verge  of  the  anus  in  the 
median  line. 

The  staff  is  firmly  held  with  the  handle  inclined  toward  the  abdomen, 
and  the  overlying  tissues  are  penetrated  by  the  knife,  held  horizontally  and 


Fig.  1403.— Wood's  staff  and 
bisector. 


1196 


OPERATIVE  SURGERY. 


with  the  edge  turned  to  the  left,  until  the  groove  in  the  staff  is  readied ; 
then  the  knife  is  pushed  forward  into  the  bladder  upon  the  staff.  As  it  is 
withdrawn,  an  incision  three  fourths  of  an  inch  long  is  made  downward  and 
outward  toward  the  fore  part  of  the  tuber  ischii.  This  incision  is  completed 
by  being  continued  directly  downward  about  half  an  inch.  If  necessary  it 
can  be  extended. 

The  Results. — A  little  over  10  per  cent  are  re])orted  to  have  died  from 
operation  by  this  method. 

The  Medio-bilateral  Lithotomy. — The  medio-bilateral  operation  was 
brouglit  to  the  notice  of  the  {)rofession  by  Civiale,  and  afterward  was  cham- 
pioned  in  this  country  by  Briggs,  of  Nashville.     The  staff  for  the  median 


Fio.  1404. — Briergs's  modified  lithotome, 


method  is  introduced  with  the  patient  placed  in  the  usual  position ;  the  rec- 
tum is  drawn  backward  by  the  finger,  and  an  incision  is  made  through  the 
median  line  into  the  staff  an  inch  and  a  half  in  length,  beginning  about  half 
an  inch  in  front  of  the  anus. 

The  lithotome  (Fig.  1404,  a)  is  then  introduced  into  the  groove,  carried 
into  the  bladder,  the  blades  are  separated  half  an  inch,  limited  by  the  pointed 
slide  on  the  handle,  and  the  instrument  is  withdrawn,  thus  dividing  the 
prostate,  and  enlarging  the  wound  on  either  side  a  quarter  of  an  inch 
throughout.  The  wound  is  then  dilated  and  the  stone  removed  in  the  usual 
manner.  If  too  large  it  may  be  crushed.  The  writer  modified  Briggs's 
instrument  somewhat  by  introducing  an  independent  guiding  stem  which 
steadies  the  cutting  blades  during  the  withdrawal  of  the  instrument  from 
the  bladder  (Fig.  1404,  h). 

The  Results. — Briggs  reported  the  mortality  as  1  in  37  cases,  which  is 
certainly  an  astonishing  result. 

Suprapubic  Lithotomy. — The  suprapubic  or  high  operation  was  done 
near  the  middle  of  the  sixteenth  century.  Since  this  time  it  has  found 
favor  at  several  epochs,  and  is  now  again  being  strongly  advocated  and  quite 
generally  practiced.  The  various  relapses  of  the  method  depended,  without 
doubt,  more  upon  the  determination  of  its  exponents  to  make  it  an  exclusive 
operation  than  upon  its  own  intrinsic  defects. 

The  following  conditions  call  for  the  employment  of  this  method  :  great 
prostatic  hypertrophy;  inability  to  extract  the  stone  through  the  perinfpum 
on  account  of  its  size  ;  encysted  stone  ;  large  stone  with  a  contracted  bladder 
surrounding  it  firmly ;  impermeability  of  the  urethra.     The  method  permits 


OPERATION'S   ON    'I'lIM    I'KI.NAKV    BLADDER. 


1197 


of  a  complete  inspection  of  the  bladder,  obviates  all  danger  of  injury  of  the 
structures  of  the  neck  of  the  organ,  and  establishes  the  wound  in  a  favorable 
site  for  cleanliness. 

Tlu'  AiKitoinicid  Points. — Tlie  median  line  of  the  body  at  this  situation 
can  be  determined  by  measurement  and  by  palpation.  The  symphysis  pubis 
and  the  sui)rapubic  notch  are  infallible  bony  guides  to  the  lower  limit  of  the 
median  line,  and  can  be  easily  located,  except  in  cases  with  marked  adi})ose 
deposit.  The  liuea  alba  at  this  situation  is  frecpiently  too  indistinct  to  be 
relied  upon  as  a  guide.  The  ])yramidal  muscles  located  beneath  the  sheath 
of  the  rectus  should  not  be  mistaken  for  the  rectus.  The  direction  ajid 
marked  development  of  their  tibers,  and  their  superficial  location  should  make 
their  recognition  easy.  The  su])rai)ubic  notch  can,  at  this  time,  be  readily 
felt,  and  will  indicate  the  lower  limit  of  the  median  line  positively.  The 
separation  of  the  borders  of  the  pyramidal  muscles  and  the  lower  extremities 
of  the  recti  abdominis  and  the  divided  borders  of  the  transversalis  fascia — 
lying  immediately  beneath  the  latter — from  each  other,  will  open  directly 
iuto  the  anterior  limit  of  the  space  of  Retzius,  otherwise  known  as  the  pre- 
vesical space  (Fig.  1378,  i\h).    The  prevesical  space  lies  between  the  bladder 


Fig.  1405. — Cut  from  frozen  serlion.  I'll.nl- 
der  contains  ten  fluid  ounces,  a.  Pri>- 
vesical  fold  of  peritonaeum,  h.  Retro- 
vesical peritoneal  fold. 


Fid.  14()(i.— Bladder  distended  with 
twenty  fluid  ounces,  a  and  h. 
Folds  of  peritona'um. 


and  the  pubis,  and  contains  a  variable  amount  of  fatty  tissue  resting  on  the 
bladder  and  continuous  with  the  pelvic  and  subperitoneal  tissues.  The 
bladder  here  is  uncovered  with  peritonoeum,  and  is  not  approachable  from 
without  in  an  undistended  state,  except  with  great  danger  of  injury  to  the 


1198 


OPERATIVE  SURGERY. 


fold  of  peritonaeum  reflected  upon  it  from  the  abdomen  above.  The  bladder 
is  known  by  its  pinklike  color,  oval  outline,  elasticity  on  palpation,  and  the 
appearance  of  the  outer  muscular  fibers.  If  a  doubt  of  its  identity  then 
occur  the  use  of  the  hypodermic  syringe  will  decide  the  question.  The  space 
of  Ketzius  is  of  great  importance,  as  its  extent  affords  opportunity  for  wide 
urinary  infiltration  and  connective-tissue  sloughing.  And  especially  is  this 
true  if  rough  and  prolonged  disturbance  of  its  contents  be  practiced.  If 
the  bladder  and  rectum  be  empty  the  apex  of  the  bladder  and  the  anterior 
peritoneal  fold  are  below  the  upper  margin  of  the  pubis  in  all  instances. 
As  the  apex  of  the  organ  is  raised  above  the  pubis  the  ])eritoneal  fold  and 
the  contiguous  intestines  are  correspondingly  elevated,  and  the  prevesical 
space  is  brought  into  position  for  safer  operative  attack  (Figs.  1405  and 
1406).  The  base  of  the  bladder  is  raised  upward  by  rectal  distention  irre- 
spective of  distention  of  the  bladder  itself  (Fig.  1407).  But  the  apex  of 
the  bladder  is  not  elevated  by  rectal  distention  unless  the  bladder  also  be 
more  or  less  distended  (Fig.  1408).  Distention  of  the  bladder  alone 
increases  its  height  in  the  abdominal  cavity  and  raises  the  peritoneal  fold 


Fig.  1407. — Bladder  contains  six  and  a 
half  fluid  ounces.  Rectum  distended 
with  fifteen  fluid  ounces,  a  and  b 
mark  the  peritoneal  folds. 


Fig.  1408. — Bladder  contains  fourteen  fluid 
ounces.  Rectum  distended  with  sixteen 
fluid  ounces,  a  and  b.  Folds  of  perito- 
naeum. 


proportionately  to  the  degree  of  the  vesical  distention;  rectal  distention  at 
this  time  produces  a  correspondingly  similar  result.  The  higher  position 
and  the  greater  mobility  of  the  bladder,  in  children,  permit  it  to  rise,  when 
distended,  to  a  much  safer  position  for  operation  than  in  the  adult.  How- 
ever, a  Avell- distended  normal  adult  bladder  is  safely  placed  for  ojieration  if 


OPERATIONS   ON   THK    URINARY    liLADDEIl. 


111)9 


needed  care  be  exercised.  But,  when  supi)lemeuLed  willi  rectal  distention, 
all  common  operative  dangers  are  eliminated  (Fig.  1409). 

The  I'repitrdtion  of  the  Patient. — 'i'he  preparation  of  tlie  patient,  so  far 
as  the  mucous  anil  cutaneous  surfaties  are  concerned,  has  l)een  indicated 
already  in  the  operation  of  cystotomy,  lithotomy,  etc.  In  this  instance  it  is 
essential  that  the  bhulder  l)e  thoroughly  cleansed  frequently  before,  and 
again  at  the  time  of  opera- 
tion, to  remove,  as  far  as 
possible  from  contact  with 
the  wound  surfaces  the  in- 
fecting iniluences  that  often 
attend  the  changes  incident 
to  the  presence  of  vesical 
calculus. 

T}ie  Operation.  —  Place 
the  patient  on  the  back  ;  in- 
duce profound  anaesthesia; 
wash  out  the  bladder  with 
a  warm  solution  of  boric 
acid ;  leave  the  catheter  in 
the  bladder.  Smear  with 
vaseline,  fold  and  introduce 
the  rectal  bag  well  above 
the  sphincters,  causing  it  to 
lie  in  the  hollow  of  the 
sacrum.  Introduce  into  the 
rectal  bag  ten  or  twelve 
ounces  of  warm  water  and 

clamp  the  tube.  Introduce  into  the  bladder  ten  or  fifteen  ounces  of  a  warm 
solution  of  boric  acid,  carefully  noting  the  ascent  of  the  bladder  and  arrest- 
ing the  flow  as  soon  as  the  organ  is  suitably  distended.  Withdraw  the  cathe- 
ter and  close  the  penis  with  a  rubber  band,  or  clamp  the  catheter  and  apply 
the  band  as  before. 

The  bladder  is  then  exposed  and  opened  in  the  manner  described  under 
"  suprapubic  cystotomy  "  (page  415).    Extract  the  stone  carefully  (Fig.  1410), 

examine    for    another, 


and  for  the  presence  of 
debris;  remove  the  con- 
striction from  the  penis 
and  wash  out  the  blad- 
der through  the  urethra, 
if  washing  be  needed. 
Whether  or  not  the  bladder  shall  be  sutured  and  the  abdominal 
wound  closed,  is  a  question  that  has  given  rise  to  much  discussion 
and  is  not  yet  settled.  In  children,  and  in  adults  with  healthy 
bladders  and  limited  adipose  deposit,  immediate  union  can  be  safely  prac- 
ticed, provided  the  prevesical  space  be  drained  through  a  small  opening  at 


Fig.  1409. — Kubl)er  bair  IVn-  distention  of  rectum. 


Fig.  1410. — Hooked  gorget  for  holding  up 
the  bladder  while  searching  its  in- 
terior. 


1200 


OPERATIVE   SURGERY. 


the  most  dependent  part  of  the  iibdoniinal  wound.  And  even  then  frequent, 
careful,  and  intelligent  scrutiny  should  be  exercised  to  detect  the  first  mani- 
festation of  the  escape  of  urine.  In  every  instance  of  partial  or  complete 
closure,  a  limited  surface  at  either  side  of  the  vesical  wound  should  be  fresh- 
ened and  so  united  with  interrupted  sutures  of  silk  or  chromicized  catgut 

as  to  secure  coaptation  of 
raw  surfaces.  The  Gushing 
(Fig.  1411),  or  Halsted 
(Fig.  850),  or  double  purse- 
string  (Fig.  1412),  or  the 
interrupted  suture  (Fig. 
1413)  are  employed,  ac- 
cording to  the  practice  of 
the  operator.  The  sutures 
should  never  pass  through 
the  mucous  lining  of  the 
organ,  and  a  round  needle 
should  be  used  in  the  sew- 
ing. While  there  are  many  instances  of  complete  closure  recorded  by  expe- 
rienced surgeons,  both  with  and  without  interrupted  or  continuous  drain- 
age through  the  penis  or  peringeum  for  two  or  three  days,  followed  by  per- 
fect results,  yet  it  nevertheless  happens  that  in  the  majority  of  instances 


Fig.  1411. — Cushing's  suture. 


Fig.  1412. — Brenner's  double 
purse-string  suture. 


Fig.  1413. — MacCormac's  method  of  placing 
interrupted  sutures. 


in  which  complete  primary  closure  is  made,  ])rompt  and  permanent  union 
does  not  take  place.  Tlierefore,  if  there  be  any  doubt  regarding  the  proper 
course  to  pursue  in  this  respect,  the  visceral  wound  should  not  be  entirely 
closed,  and  suitable  drainage  should  be  established.    In  case  immediate  union 


OPERATIONS   ON    'I'llK    l'KINAIi^     I'.I.A  DDHi:.  12(»1 

be  souglit  for,  dniiiia^^^'  of  the  abdoiniiKil  wound,  as  already  stated,  sliould  be 
practiced,  and  the  hlachler  relieved  with  a  catlieter  at  regular  intervals,  if 
continuous  di-aina_i;e  be  not  employed.  /ii/(/i/(/ier  proposed  and  practiced  an 
intraperitoiu'al  method  of  operation  as  follows:  He  thoroughly  cleansed  the 
bladder  and  the  tield  of  operation,  inserted  and  retained  in  the  organ  a  large 
catheter,  exposed  the  anterior  wall  of  the  bladder  in  the  usual  manner — but 
more  extensively  opening  the  peritoneal  cavity — drew  u})  and  temporarily  lixed 
the  bladder  to  the  borders  of  the  abdominal  wound  by  sewing  the  two  tissues 
together  so  as  to  exclude  the  ])eritoneal  cavity  completely  from  the  entrance 
of  urine,  opened  the  bladder,  extracted  the  stone,  removed  the  temporary 
sutures,  and  closed  the  openings  in  the  bladder  and  abdomen  at  once,  in  the 
usual  manner  of  closing  wounds  of  serous  membranes.  This  method  affords 
abundant  space  of  entrance  to  the  bladder,  permits  its  wall  to  be  drawn 
upward  into,  and  possibly  outside,  the  wound,  and  assures  one  of  prompt  and 
firm  union  because  of  the  apposition  of  serous  surfaces.  Harrington  strongly 
favors  this  plan  for  the  reasons  already  stated. 

The  Complications. — Rupture  of  the  bladder  or  of  the  rectum  is  a  com- 
plication of  great  significance,  \vhich  should  be  carefully  guarded  against  by 
attention  to  the  exciting  and  predisposing  influences  that  occasion  it.  Sep- 
tic infiltration  of  the  space  of  Retzius  is  a  dangerous  and  often  a  fatal  com- 
plication. Free  incisions  at  dependent  parts  to  secure  good  drainage  and 
the  free  use  of  antiseptic  solutions  are  the  needed  measures  of  treatment  in 
such  cases.  Rough  handling  and  infection  of  the  connective  tissue  of  the 
prevesical  space  by  urinary  infiltration  or  infection  are  the  common  causes 
of  this  condition.  In  order  to  prevent  these  complications  in  infected  cases, 
Senn  advises  that  the  operation  be  divided  into  two  stages.  At  first  the 
bladder  is  exposed  and  the  wound  packed  with  gauze  for  four  or  five  days, 
until  the  spaces  are  closed  by  granulation,  when  the  visceral  incision  is 
made  with  cocain  anaesthesia  in  the  usual  manner.  Suppression  of  urine 
from  kidney  disease  is  often  provoked  by  suprapubic  lithotomy,  the  same  as 
by  other  operations  on  the  bladder. 

The  Frecantions. — If  the  rectum  be  diseased  the  bag  should  not  be 
employed.  If  the  bladder  be  greatly  diseased,  dilatation  should  be  practiced 
cautiously  and  perhaps  dispensed  with  entirely,  and  a  perineal  operation  per- 
formed. The  introduction  of  twenty-three  ounces  of  fluid  has  caused  rup- 
ture of  a  healthy  adult  rectum  ;  the  injection  of  four  ounces  has  caused 
rupture  of  a  diseased  adult  bladder.  Rupture  will  rarely  happen  if  not 
more  than  eight  or  ten  ounces  are  introduced  into  the  bladder  and  rectum 
respectively.  In  either  instance  injection  should  cease  when  undue  resist- 
ance is  experienced.  Adhesion  of  the  peritonaeum  to  the  pubis  may  prevent 
the  ascent  of  the  bladder.  In  feel)le  and  relaxed  subjects  the  bladder  rises 
from  out  of  the  pelvis  freer  and  further  than  in  those  of  dissimilar  states. 
It  is  essential,  therefore,  to  comprehend  the  possibility  of  the  presence  of 
contraindicating  and  restraining  influences  in  distending  the  viscera,  or  rup- 
ture may  ensue.  If  the  visceral  and  abdominal  wounds  are  closed  at  once, 
it  is  wise  to  test  the  line  of  union  of  the  former  by  moderate  distention  of 
the  organ  with  air  or  fluid  before  the  latter  is  closed.     For,  if  a  defect  be 


1203 


OPERATIVE   SURGERY. 


found,  it  can  then  be  repaired  before  closure  of  the  abdonnnal  wound,  and 
in  tht!  presence  of  doubtful  integrity  of  the  line  of  nnion  the  abdominal 
wound  can  be  drained. 

7'Ae  Remarks. — Whether  the  bladder  or  the  rectum  be  distended  first  is 
a  matter  of  no  special  importance  in  ordinary  cases.  However,  when  a  fear 
of  the  lack  of  structural  integrity  of  the  bladder  or  of  the  bowel  be  present, 
the  impaired  viscus  should  be  favored,  and  the  requirement  of  the  healthy  one 
correspondingly  increased.  Since  the  distended  rectal  bag  obstructs  the  cir- 
culation of  the  bladder,  thereby  congesting  its  field  of  operation,  the  later  in 
the  course  of  the  procedure  the  bag  is  distended  the  better  it  is,  in  this 
regard.  Still,  as  the  bleeding  is  not  severe  and  can  be  promptly  checked 
by  ordinary  means,  by  a  removal  of  the  bag  and  opening  the  bladder,  the 
bleeding  is  not  entitled  to  special  significance,  except  in  rare  instances.  In 
children  and  thin  adult  subjects,  rectal  distention  need  not  be  employed, 
especially  if  the  patient  be  placed  in  Trendelenburg's  position.  This  pos- 
ture is  especially  serviceable  in  the  instances  of  a  pendulous  abdomen,  and 
when  the  light  can  thus  be  utilized  to  the  best  advantage.  The  finger  is 
employed  to  detect  the  stone  before  the  forceps  is  introduced,  and  the 
opening  is  then  made  of  the  necessary  size  to  admit  of  the  extraction  of  the 
stone  without  injury  to  the  tissues.  Some  operators  distend  the  bladder 
with  air  instead  of  fluid,  claiming  that  air,  being  more  compressible  than 
fluid,  is  less  liable  to  cause  rupture  (Bristow).  Brown  commends  the  use  of 
air,  and  advises  that  the  bladder  be  thoroughly  cleansed  through  a  rubber 
catheter,  which  is  then  fastened  in  place  and  retained  for  the  purpose  of  the 
Introduction  of  air.  The  apparatus  employed  in  the  act  is  not  disconnected 
at  first,  but  is  left  temporarily  attached,  so  that  on  exposure  of  the  fascia 

additional  inflation  will  cause  the  organ 
to  approach  still  nearer  to  the  surface. 
Finally,  the  catheter  is  clamped  to  pre- 
vent the  escape  of  air,  and  the  pump  or 
syringe  is  removed.  Brown  commends 
the  bicycle  air  pump  for  the  purpose,  and 
states  that  each  in-and-out  action  of  the 
piston  is  about  equal  in  effect  to  the  intro- 
duction of  an  ounce  of  water.  He  likewise 
recommends  that  the  rectal  distention  be 
dispensed  with  when  air  is  employed  in  the 
bladder.  Either  of  the  agents,  when  dis- 
creetly employed,  meets  the  indications, 
and  is  not  a  source  of  especial  danger. 
In  the  absence  of  suitable  forceps  the  stone 
Fig.  1414.— Removal  of  the  stone  from  rn^v  be  removed  from  the  bladder,  espe- 
shallow    bladder    by    interlocked      •   ii     •/.   •,    ,        ■,    ^^         ^  j-   •    l^ 

fingers.  cially  if  it  be  shallow,  by  means  oi  inter- 

locked fingers  (Fig.  1414). 
Tlie  After-treatment. — If  the  bladder  be  closed   completely,  the  after- 
treatment  relates  to  vigilant  attention  to  forestall  infiltration,  rather  than  to 
medical  measures.     If  the  bladder  be  not  closed  entirely,  the  bed  should  be 


Ui'KliATlUNS   UN    THE    LUINAKY   BLADDER.  1203 

protected  by  waterproof  sheets  and  with  spon<jes ;  tlie  exposed  parts  of  the 
body  th<)rou.i,ddy  anointed  with  vaseline ;  the  wonnd  sprinkled  with  iodo- 
form ;  the  pelvis  well  separated  from  the  bedclothes  by  a  large  cradle,  both 
for  convenience  and  ventilation.  The  urine  should  be  absorbed  at  the 
wound  with  numerous  sponges  and  absorbent  cotton  applied  to  the  part,  and 
changed  perhaps  two  or  three  times  an  hour.  Of  course,  the  siphon  drain- 
age, already  described  (page  IVriij  et  scq.),  should  be  employed,  and,  when 
efficient,  will  relieve  the  patient  and  the  attendants  of  much  trouble.  How- 
ever, any  foviu  of  drainage  is  often  fickle,  on  account  of  the  uncertainty  of 
action  contingent  on  the  manner  of  adjustment  and  the  co-operation  of  the 
patient.  The  wound  and  the  bladder  should  be  thoroughly  cleansed  when 
needed,  and  the  patient  caused  to  sit  up  as  soon  as  practicable.  The  wound 
in  the  bladder  usually  closes  in  from  two  to  four  weeks.  Bandaging  and 
strapping  interfere  with  drainage  and  do  not  hasten  repair. 

T/ie  Results. — The  death  rate  is  about  13  per  cent  in  practice  at  large, 
but  is  much  less  in  the  hands  of  those  skilled  in  the  selection  and  employ- 
ment of  the  method. 

The  Choice  of  Operation. — The  choice  of  operation  in  the  various  cases 
of  stone  in  the  bladder  is  not  always  easy  to  determine.  In  a  general  way 
the  determining  reasons  of  choice  are  indicated  already  in  connection  with 
the  respective  operations.  It  seems  proper  to  add  in  this  connection  the 
statistics  of  White,  relating  to  the  influence  of  age  on  the  outcome  of  opera- 
tive methods. 

Infancij  to  Puberty. — Perineal  lithotomy,  602  cases;  suprapubic  lithoto- 
my, 637  cases;  litholapaxy,  284  cases,  with  a  death  rate  of  3.1,  13.1,  and  1.7 
per  cent  respectively. 

Pulierty  to  Middle  Age. — Perineal  lithotomy,  226  cases;  suprapubic 
lithotomy,  159  cases;  litholapaxy,  485  cases,  with  a  death  rate  of  9.7,  11.3, 
and  4.5  per  cent  respectively. 

Old  Age. — Perineal  lithotomy,  69  cases;  suprapubic  lithotomy,  91  cases; 
litholapaxy,  581  cases,  with  a  respective  death  rate  of  19,  18,  and  7  per 
cent. 

Cunningham.,  according  to  his  own  experience  (133  cases),  regards  litho- 
lapaxy as  suitable  for  all  but  3  per  cent  of  the  cases. 

Irrespective  of  the  aforegoing  results  it  should  not  be  overlooked  that 
one  is  likely  to  succeed  best — other  things  being  equal — in  the  use  of  the 
method  of  ]iractice  with  whicli  he  is  the  most  familiar. 

Foreign  Bodies  in  the  Urethra. — It  is  rare  indeed  that  stones  form  in  the 
urethra.  Usually  they  are  arrested  there  during  the  passage  of  the  urine. 
The  prostatic  sinus,  the  membranous  urethra  just  behind  the  anterior  layer 
of  the  triangular  ligament  (Fig.  1378,  rf),  and  the  navicular  fossa,  are  the 
common  sites  of  lodgment.  Sometimes  they  are  arrested  at  the  peno-scrotal 
junction.  A  marked  narrowing  at  any  part  of  the  urethra  may  arrest  their 
passage.  Complete  and  incomplete  obstruction  may  be  caused,  depending 
on  the  diameter  of  the  stone  or  that  of  the  canal.  The  degree  of  the  obstruc- 
tion is  indicated  practically  by  the  arrest  and  the  freedom  of  the  flow  of  the 
urine  through  the  urethra. 
82 


1204 


OPERATIVP]  SURGERY. 


Fig.  1415. — Instruments  employed  in  removal  of  forei<rn  bodies  from  urethra  and  Madder. 

a.  Mercier's  duplicator  for  use  in  the  bladder,  h.  Collin's  broken  catheter  extractor,  c. 
Galante's  crusher,  d.  Nelaton's  urethral  cruslier.  e.  Reliquet's  urethral  crusher. 
/.  Mathieu's  lithotrite.  g.  Old  i)attern  of  urethral  lithotrite  with  calculus  in  jaws. 
h.  Mathieu's  curved  urethral  forceps,  i.  Thorn fison's  urethral  forceps.  /.  Short- 
jawed  urethral  forceps,  k.  Syringe.  I.  Needle  for  "needling"  stone  in  urethra,  m. 
Urethral  spatula  n.  Loop  of  wire  and  of  silkworm  gut  to  lasso  urethi-al  calculi. 
0.  Silver  probe,    p.  Urethral  scoop,     q.  Wheelhouse's  staff  for  perineal  section. 


UrEKATlONS   ON    TUK    L'KINAUV    BLA  DDKIJ. 


1205 


The  'rreatinoii. — In  jiartial  obstruction,  the  sudden  arrest  of  the  flow  of 
urine  and  tiie  distention  of  the  urethra  attendant  on  grasping  the  head  of 
the  penis  during  micturition  will  cause  dislodgmcnt  and  escape  of  the  stone. 
Distention  of  the  canal  in  front  by  an  oleaginous  injection,  or  the  introduc- 
tion and  sudden  removal  of  a  large  blunt  sound  during  urinary  effort,  mav 
meet  the  demand.  If  situated  far  in  front,  the  stone  may  be  worked  out 
by  manipulation  with  the 
lingers,  aided  by  urinary 
pressure.  If  soft,  it  may  be 
crushed  with  the  fingers  and 
washed  out  l)y  the  urine. 
If  located  behind  the  coni- 
pressor  urethra?,  it  may  be 
pushed  back  into  the  bladder 
during  a  urinary  effort  and 
crushed  later.  A  urethral 
scoop  may  be  insinuated  be- 
hind it  while  it  is  steadied 
with  the  fingers,  or  a  small 
urethral  stone  cruslier  may 
be  used  in  a  similar  man- 
ner, when  the  obstruction 
may  be  removed  intact  or 
crushed  and  removed  (Fig. 
1415).  It  may  be  caught 
and  removed  by  means  of 
the  straight  or  curved  alli- 
gator forceps  (Fig,  1415). 
Failing  in  these  expedients, 
it  can  be  readily  removed 
through  a  small  free  incision 
into  the  urethra  at  the  site 
of  lodgment.  It  is  better 
that  the  stone  be  removed 
through  a  free  incision  than 
to  cause  laceration  of  the 
urethra  in  the  efforts  of  re- 
moval by  other  methods 
(Figs.  1416  and  1417).  An  incised  wound  of  the  urethra  usually  heals 
promptly.  It  may  be  feasible  to  needle  it,  as  is  sometimes  practiced  for 
gallstone  obstruction  (page  814).  Sharp-pointed  objects,  like  pins,  needles, 
etc.,  can  be  removed  as  indicated  in  the  illustrations  (Figs.  1418,  1419,  and 
1420). 

Foreign  Bodies  in  the  Bladder. — An  unlimited  variety  of  foreign  bodies 
gain  access  to  the  bladder  because  of  violence,  defective  instruments,  the 
mishaps  attending  operative  practice,  and  those  incident  to  the  acts  of  sexual 
perversion,  etc.     The  nature,  shape,  and  size  of  a  foreign  body,  and  the  re- 


FiG.  1416. — Suture  of  urethra  after  incision  for  removal 
of  stone,  etc.  a.  Forceps,  b.  Superficial  perineal 
fascia,  c.  Accelerator  urina^  muscle,  d.  Urethra. 
e.  Sound  or  catheter  for  support  of  urethral  walls 
during  sewing.  /.  Depth  to  which  stitches  are 
carried,    g.  Sewed  surface  of  urethra. 


1206 


OPERATIVE  SURGERY. 


ceiitness  of  the  entrance  are  all  matters  of  special  significance  bearing  on  the 
question  of  promptness  and  method  of  treatment.  Tlie  things  not  suited  to 
enter  and  traverse  the  urethra  should  be  taken  away  by  the  perineal  or  sup- 
rapubic routes.  Small  and  freely  movable  objects  may  be  removed  by  the 
evacuator  (Fig.  1360  et  seq.)  or  lithotrite.  Long,  flexible,  and  suitably  bent 
objects  can  be  removed  by  instruments  designed  for  the  purpose  (Fig.  1415). 
All  objects  are  easier  and  safer  removed  early  in  the  history  of  the  case, 

before  incrustation  or  cys- 
titis attend  their  presence. 
It  is  proper  to  note  at  this 
time  that  long  objects  usu- 
ally lie  transversely  in  the 
bladder,  and  when  the  organ 
is  empty  an  object  longer 
than  four  inches  is  thus 
placed,  while  one  five  or 
more  takes  a  vertical  or 
oblique  position.  The  em- 
ployment of  the  cystoscope, 
to  determine  the  character- 
istics of  the  body,  its  location 
and  direction  should  not  be 
overlooked.  If  incrustation 
have  already  taken  place,  the 
gentle  use  of  the  lithotrite 
may  be  sufficient  to  dislodge 
it,  especially  if  deposited  on 
a  flexible  substance. 

Catheters  may  be  re- 
moved by  withdrawal  in  the 
long  axis  (Fig.  1415),  or  by 
doubling,  if  the  caliber  of 
the  urethra  will  permit. 
Much  patience  and  skill  are 
needed     to    locate    and    so 

Fig.  1417. — Suture  of  deep  tissue  over  line  of  uretfiral    change  the  direction  of  rigid 
sewing,     n.  Superficial  perineal  fascia,     h.  Accel-    u^j;"    u„   _       .  „    ,^f    •„„+..„ 
eratorurin;e  muscle,    c.  Line  of  sewing  of  urethra,    bodies   by   means   of   instru- 
ct. Sewing  muscular  flaps  over  urethral  incision.        ments  having,    or  devoid  of, 

special  mechanism  to  secure 

their   harmless   delivery.     The   presence   of   cystitis   or   of   kidney  disease 

admonish  that  care  be  practiced  in  every  manner. 

Lithotomy,  etc.,  in  the  Female. — Aside  from  lithotrity  and  litholapaxy,  a 

stone  may  be  removed  from  the  female  bladder  by  dilatation  of  the  urethra, 

and  by  vaginal  and  suprapubic  lithotomy. 

Dilataiion  of  the  Urethra. — Dilatation  of  the  urethra  is  applicable  to 

the  removal  of  small  stones.     A  stone  an  inch  in  diameter  can  be  removed 

thus  without  much   danger  of   troublesome   incontinence   of  urine;  when 


OPEIIATIOXS   OX    TIIH    LUlINAIiV    I'.l..\  DDKi;. 


120' 


larger  than  this,  another  method  should  l^e  practiced.  The  dihitation  can 
be  accomplished  by  largo  sounds,  graded  uterine  stems,  followed  in  turn 
by  the  tingera.      Instruments  specially  designed  for  the  purpose  are  often 

employed.      After    suitable    dilatation    is 
secured,  the  stone  is  removed  with  slender 


Fig.  1418. — The  removal  of  a  pin 
from  the  urethra,  first  step.  Caus- 
ing pin  to  puncture  tissues. 


Pig.    1419. — The   removal   of  a  pin   from   the 
urethra,  second  step.     Turning  pin. 


The  Precautions. — Overdistention  of  the  passage  may  cause  rupture  of 
the  urethral  structure  and  lead  to  incontinence.  If  the  stone  plus  the 
thickness  of  the  forceps  be  too  large,  the  stone  should  be  crushed  and 
the  fragments  removed  as  in  the  male. 

Tlie  vaginal  method  consists  in  con- 
necting the  vagina  with  the  cavity  of  the 
bladder  by  a  longitudinal  incision  made 
in  the  median  line  of  the  vagina,  the 
length  varying  according  to  the  size  of 
the  stone.  The  patient  is  placed  on  the 
back  and  a  grooved  staff  is  introduced 
into  the  bladder;  the  position  of  the 
groove  is  ascertained  by  the  finger,  and 
the  tissues  between  the  finger  and  the 
groove  are  divided  by  a  scalpel  or  scis- 
sors. The  stone  is  grasped  and  removed 
by  forceps ;  if  too  large,  it  should  be 
crushed  and  removed  piecemeal. 

The  wound  in  the  bladder  should  be 
closed  at  once  if  practicable  ;  if  not,  it 
may  be  left  to  heal  spontaneously — which 
it  often  promptly  does — or  can  be  closed 


Fig.  1420. — Tlie  removal  of  a  pin  from 
the  urethra,  third  step.  Passing 
head  out  of  meatus. 


120S  OPERATIVE  SURGERY. 

tliereafter  by  au  independent  operation.  Tlie  tendency  to  the  formation 
of  phosphatic  deposits  during  the  healing  process  is  controlled  by  frequent 
irrigation  with  tepid  water  only,  or  by  tepid  water  acidulated  with  nitric  or 
hydrochloric  acid.  A  solution  of  the  acetate  of  lead — one  grain  to  the  ounce 
of  warm  water — is  highly  extolled  for  this  jiurpose. 

Suprapubic  LWiotomy  in  the  Female. — If  the  stone  be  too  large  for 
removal  by  the  vagina  and  too  hard  for  crushing,  the  suprapubic  method  is 
then  advisable.  The  technique  of  this  method  in  the  female  is  similar  to 
that  in  the  male. 


CIIAPTEIJ    XVIII, 


nriJUATTOAs  ox  Till-:  sch'orrM  and  penis. 


Hydrocele  of  the  Tunica  Vaginalis  Testis. — The  operative  measures  for 
the  treatment  of  this  aflfectioii  are  tlie  palliative  and  radical  measures. 

Tlie  Anatomical  Points. — The  testicle  is  variously  situated  to  hydrocele, 
usually  behind  (Fig.  14-^1),  sometimes  below  (Figs.  1422  to  142.5),  and  rarely 
indeed  in  front  of  it.  The  superficial  tissues  of  the  scrotum  may  cover 
loosely  the  fluid  collection  or  be  drawn 
smoothly  around  it,  depending  on  the  de- 
gree of  the  distention.  The  scrotal  vessels 
can  commonly  be  seen  coursing  through 
the  tissues  near  to  the  surface.  Not  infre- 
quently a  hernial  protrusion  trespasses  on 
the  region.  The  position  of  the  testicle 
and  the  presence  of  hernia  ought  always 
to  be  determined  before  the  operation  is 
begun.  Transmitted  light  will  indicate  the 
relation  of  the  fluid  to  the  testicle  and  often 
determine  the  presence  of  intestine.  How- 
ever, the  history  of  the  case  and  the  influ- 
ence on  the  position  of  the  intestine  of 
dorsal  decubitus  are  the  better  determina- 
tive means  of  the  latter  conditions. 

In  a  t)inocular  hydrocele  (Fig.  1426)  a 
constricted  part  of  the  vaginal  process  ly- 
ing in  the  inguinal  canal  separates  a  hydro- 
cele of  the  tunica  vaginalis  from  a  dis- 
tended vaginal  process  above,  shut  off  from  the  peritoneal  cavity.  F'rom 
change  in  posture  or  alternating  pressure  above  and  below  a  variation  in  the 
sizes  of  the  respective  enlargements  can  be  seen. 

The  Palliative  Treatment.— The  palliative  treatment  relates  to  the  evacu- 
ation of  the  fluid  from  time  to  time,  as  recurring  distention  demands,  by 
tapping.  Comfort  rather  than  cure  is  sought  for,  as  this  measure  rarely 
indeed  cures  the  affection,  unless  acute  inflammation  supervenes.  Strict 
asepsis  should  be  practiced  in  tapping,  to  obviate  unbidden  inflammatory 
sequels. 

Tapping. — Tapping  is  a  simple  process,  requiring  a  small  trocar  and 
cannula,  or  an  aspirating  needle,  or  an  instrument  of  a  similar  nature.     The 

1209 


Fi(i.  1421. — Usual  form  of  hydrocele. 


1210 


OPERATIVE  SURGERY. 


patient  is  caused  to  sit  upright  on  tlie  edge  of  a  chair  witli  the  limbs  sepa- 
rated, or  to  lie  on  a  lounge,  and  the  enlargement  is  seized  by  the  left  hand 
and  the  tissues  made  tense  over  its  anterior  surface.     The  testicle  is  care- 


FiG.  1422.— Hydrocele  Fig.  1423.— Hydrocele  Fig.  1424.— Encysted  Fig.  142.j.— Hydro- 

of  the  cord  commu-  of  the  cord  commu-  hydrocele     of     the  cele  of  the  tunica 

nicating  with  the  tu-  nicating     with    the  cord.  vaginalis  testis, 

nica  vaginalis  testis.  peritoneal  cavity. 

fully  located,  and  the  course  of  the  scrotal  vessels  as  cautiously  avoided. 
The  instrument,  guarded  by  the  end  of  the  finger  to  limit  the  extent  of 
the  puncture  (Fig.  1427),  is  quickly  plunged  upward  and  backward  into 
the  scrotum  at  about  the  junction  of  its  middle  and  lower  thirds.     As  the 

fluid  escapes,  the  end  of  the  can- 
nula is  turned  away  from  the  tes- 
ticle, and  the  tumor  is  compressed 
carefully  to  expel  the  entire  fluid 
collection.  After  the  fluid  is  re- 
moved and  the  puncture  is  closed, 
the  scrotum  is  suspended  and  the 
2)atient  kept  quiet,  otherwise  inflam- 
mation of  the  sac  may  occur,  which, 
while  it  may  lead  to  a  radical  cure, 
will  not  be  welcome,  as  it  causes 
much  pain  and  confines  the  patient 
unexpectedly  to  bed. 

The  Precautions. — The  testicle, 
the  epididymis,  or  a  herniated  gut 
may  be  punctured  by  the  trocar,  un- 
less the  exact  location  of  the  fluid 
has  been  determined  by  transmitted 
light.  A  blunt  trocar,  or  an  ill-fitting 
cannula,  or  a  halting  thrust  may  push 
a  thickened  tunica  vaginalis  in  front  of  the  instrument.  The  puncture  of  a 
vein  of  scrotal  tissue  will  cause  extravasation  and  extensive  ecchymosis  of 
the  scrotal  structure.  An  infected  trocar  may  cause  extensive  inflammation 
and  slouffhinff  of  the  scrotal  tissue. 


Fig.  1426.— Bilocular  hydrocele.  /.  c.  Parie- 
tal layer  of  tunica,  s.  Spermatic  cord. 
n.  h.  Epididymis,  h.  Testis,  d.  Cavity 
of  diverticulum,  t.  v.  Cavity  of  the 
tunica  vaginalis  proprius.  z,  z.  Inflam- 
matory new  formation  between  the  vis- 
ceral and  parietal  layers. 


()I'KJ{ATIU.NS   ON    THE  SCliOTLM    AM)    I'KNIS. 


1-211 


The  Results. — A  repetition  of  the  openatioii  will  probably  be  required  in 
four  or  six  months,  luul  perhaps  sooner.  The  redundant  scrotum  due  to 
overdistcntion  will  soon  apjirdxiiuate  the  normal  dimensions. 

The  Radical  Measures  of  Treatment.— The  radical  measures  of  treatment 
are  injection,  incision,  and  excision  of  more  or  less  of  the  parietal  layer  of 
the  sac. 

The  Treatment  by  Injection.— The  treatment  by  injection  usually  begins 
after  the  evacuation  of  the  sac  by  tapping.  The  fluids  recommended  for  the 
purpose  are  (piite  numerous,  among  which  the  preparations  of  iodine  and  of 
carbolic  acid  ( Levis) — especially  the  latter — are  i)referred.  However,  rectified 
spirit,  port  wine,  solutions  of  the  sulphate  and  chloride  of  zinc,  and  chloride 
of  mercury,  are  each  occasionally  employed.  The  special  apparatus  ref|uired 
in  the  performance  of 
the  operation  is  the 
rubber  injection  bag, 
in  addition  to  the  or- 
dinary trocar  (Fig. 
1428).  After  thorough 
aseptic  preparation  of 
the  parts  and  with  the 
patient  sitting  or  ly- 
ing, the  trocar  is  in- 
troduced and  the  fluid 
drawn  off  as  in  tap- 
ping. The  scrotum  is 
then  seized  and  held 
steadily,  to  prevent  the 
escape  of  the  extremity 
of  the  trocar  from  the  cavity  of  the  sac,  and  the  medicated  fluid  is  thrown 
in  by  means  of  the  gum  bag.  If  the  compound  tincture  of  iodine  be  used, 
it  may  be  diluted  with  three  or  four  parts  of  water.  The  introduction  of 
three  or  four  ounces  of  the  mixture  is  quite  sufficient.  It  should  be  brought 
in  contact  with  the  apposed  surfaces  of  the  sac  by  manipulation  and  retained 
for  five  or  ten  minutes,  or  until  the  patient  complains  of  pain  or  faintness, 
and  then  allowed  to  escape  through  the  cannula.  If  the  pure  tincture  be 
used,  a  drachm  or  two  injected  in  the  same  manner,  and  allowed  to  remain, 
is  quite  sufficient.  If  the  sac  be  small,  fifteen  or  twenty  drops  may  be 
thrown  into  it  by  a  hypodermic  syringe,  without  the  previous  removal  of 
the  fluid,  and  its  diffusion  secured  by  manipulation. 

A  drachm  or  two  of  a  ten-  to  fifty-per-cent  solution  of  carbolic-acid 
crystals  in  glycerin  may  be  injected  and  allowed  to  remain.  From  half  a 
drachm  to  a  drachm  of  pure  carbolic  is  often  injected  into  the  empty 
sac,  or  while  yet  there  remains  a  small  amount  of  the  fluid  undrawn. 
Carbolic  acid  causes  less  pain  and  is  a  more  constant  and  certain  remedy 
than  iodine.  This  plan  of  practice  is  strongly  advocated  by  competent 
observers,  and  frequently  after  the  injection  the  patient  is  permitted  to  be 
out  and  around. 


Fig.  1427. — The  tapping  of  a  liydrocele  of  tunica  vaginalis. 
Showing  finger  resting  on  instrinnent  and  tumor  com- 
pressed by  hand. 


1212 


OPERATIVE   SURGERY. 


TJte  Precautions. — Inasmuch  as  the  pain  attending  tlie  injection  is 
often  severe,  and  as  fainting  may  occur,  the  recumbent  posture  is  advisable. 
The  injection  of  a  congenital  hydrocele  is  manifestly  a  dangerous  expedient, 
but  the  diagnosis  of  its  presence  will  prevent  accident.  The  unsuspected 
escape  of  the  end  of  the  cannula  from  the  sac,  and  the  consequent  introduc- 
tion of  the  injection  of  the  scrotal  tissues,  is  an  unfortunate  occurrence, 
especially  when  followed  by  extensive  inflammation  and  sloughing.  If  the 
end  of  the  cannula  thus  escapes,  an  independent  puncture  should  be  made  at 
once,  as  the  previous  opening  can  not  be  easily  found.     Injection  for  the 

cure  of  a  hydrocele  dependent  on  malig- 
nant disease  of  the  testicle  is  useless  and 
misapplied  treatment,  to  say  the  least.  Hy- 
droceles with  thick  walls  are  not  suited  for 
cure  by  injection. 

The  after-treatment  in  these  cases  con- 
sists in  putting  the  patient  to  bed,  suspend- 
ing the  scrotum  and  keeping  evaporating 
lotions  applied  to  it,  and  giving  anodynes 
to  allay  pain.  The  patient  should  remain 
in  bed  until  the  acute  symptoms  subside, 
after  which  he  is  allowed  to  go  around 
Avith  the  scrotum  suspended.  A  mouth  or 
so  is  requisite  for  the  restoration  of  the 
parts  to  the  normal  state.  Insignificant 
inflammatory  reaction  portends  a  failure  of 
the  attempt  at  cure. 

Tlie  RestiUs. — The  use  of  iodine  as  com- 
monly employed  fails  of  cure  in  nearly  18 
per  cent  of  the  cases.  The  percentage  of 
failure  from  carbolic-acid  treatment  is  less 
(13  per  cent),  and  a  second  injection  rarely 
fails  to  cure.  By  this  method  of  practice 
discomfort  and  confinement  are  reduced  to 
a  minimum.  Eare  instances  of  extension, 
local  inflammation,  of  sloughing,  of  car- 
bolic-acid poisoning,  and  of  death,  are  re- 
ported as  dependent  on  the  carbolic-acid 
treatment. 

The  Treatment  by  Incision  (Volkmann). — After  thoroughly  shaving  and 
cleansing  the  parts  and  wrapping  the  penis  in  gauze,  the  sac  is  laid  open 
for  two  inches  at  the  anterior  and  lower  aspect  of  the  tumor,  and  the  bor- 
ders of  the  tunica  vaginalis  are  stitched  to  the  edges  of  the  skin  incision 
by  six  or  seven  chromicized  catgut  ligatures  introduced  at  either  side  (Fig. 
1429).  A  large  drainage  tube  is  introduced  into  the  cavity  of  the  tunic, 
the  wound  dusted  lightly  with  iodoform,  and  dressed  with  iodoform  gauze. 
The  patient  is  kept  in  bed  for  ten  or  twelve  days,  and  the  wound  kept  clean 
by  repeated  washing  and  dressing  with  an  aseptic  solution.     The  tube  is 


Pig.  1428. — Rubber  bag  for  injecting. 


OPEUATIU.NS   UN    THE   SCICO'I'L'M    AND    I'KMS. 


1218 


Fig.  1429.— Treatment  of  hydro- 
cele by  incision,  Volkinann's 
method. 


shortened  from  day  to  diiy  and  removed  entirely  at  the  end  of  the  fir.st  week. 
The  catj^ut  sutures  are  removed  durinj,'  the  first  week,  and  by  tlie  end  of 
the  third  the  patient  is  permitted  to  resume  his  usual  mode  of  life  with 
the  scrotum  suspeiuled.    The  suspensory  should 
be  worn  for  three  or    four  months  after   the 
opiMMtion. 

The  lii'ifKtr/is. — This  oi)eration  })('rmits  (jf 
the  examination  of  the  testicle  and  determina- 
tion if  it  be  diseased.  Sometimes  an  insig- 
nificant grade  of  intlammation  of  the  testicle 
attends  the  healing  of  the  wound.  Insufficient 
drainage  may  be  followed  by  extensive  suppu- 
ration, and  even  sloughing  of  the  tissues,  espe- 
cially in  debilitated  subjects.  Light  packing 
of  the  cavity  with  iodoform  gauze  may  be  nsed 
in  place  of  the  drainage  tube.  Treves  prac- 
tices a  free  swabbing  out  of  the  cavity  of  the 
tunica  vaginalis  with  pure  liquefied  carbolic 
acid,  followed  by  free  drainage  and  frequent 
irrigation. 

The  Treatment  by  Excision  of  Parietal  Layer 
cf  Sac  (\'on  Bergmaun). — Either  complete  or  partial  excision  of  the  sac 
may  be  practiced.  In  complete  excision  prepare  the  patient  for  this  opera- 
lion  the  same  as  for  the  preceding  methods.  Make  an  incision  three  inches 
long  at  the  anterior  and  outer  aspect  of  the  hydrocele  into  the  sac ;  remove 
the  parietal  part  of  the  sac  from  the  structures  of  the  cord  and  scrotum 
down  to  the  testicle,  if  practicable,  by  blunt  dissection,  and  cut  it  away 
with  scissors.  Introduce  a  large  drainage  tube,  close  the  external  wound 
around  it  with  sutures,  and  dress  the  part  with  iodoform  gauze.  The 
patient  is  confined  to  bed  usually  for  a  week  or  ten  days. 

The  Treatment  by  Partial  Excision. — In  partial  excision  a  portion  of  the 
sac  is  cut  away  for  a  short  distance  at  either  side  of  the  primary  incision. 
As  a  modification  it  allows  a  freer  escape  of  the  discharges,  and  prevents  the 
protrusion  of  the  rigid  tunic,  but  otherwise  it  makes  no  practical  difference 
with  the  outcome.  The  external  incision  in  this  method  is  made  longer 
than  in  the  former,  affording,  therefore,  more  suitable  drainage. 

The  wound,  after  this  operation,  is  treated  in  a  similar  manner  as  in  the 
preceding  method. 

A  sfill  further  modificafioii  of  the  technique  presents,  in  our  opinion, 
the  best  operative  procedure  for  the  radical  cure  of  hydrocele.  A  long  inci- 
sion is  made  into  the  tunica  vaginalis,  and  the  condition  of  the  testis  ascer- 
tained. The  rigid  protruding  borders  of  the  divided  tunic  are  then  excised 
in  the  direction  of  the  long  axis  of  the  external  incision  about  halfway  back 
to  the  testicle,  and  the  borders  of  the  remaining  portions  stitched  by  fine  cat- 
gut to  the  subcutaneous  scrotal  tissues  corresponding  to  them.  The  cavity 
is  freely  irrigated  with  a  strong  solution  of  bichloride  of  mercury  or  carbolic 
acid,  a  drainage  tube  is  introduced,  the  scrotal  wound  closed  around  it,  and 


1214  OPERATIVE  SURGERY. 

the  flaps  quilted  together  back  to  the  line  of  division  of  the  tunica  vaginalis 
by  catgut  sutures,  to  prevent  the  contractions  of  the  dartos  from  disturbing 
the  union  and  to  limiting  the  area  of  the  wound.  The  whole  is  then  dusted 
with  iodoform  and  surrounded  by  antiseptic  gauze. 

The  wound  usually  heals  completely  under  the  primary  dressing  without 
an  unfavorable  manifestation. 

The  General  Remarks. — Only  a  total  obliteration  of  the  sac  affords  a 
positive  assurance  of  complete  and  final  cure.  A  partial  obliteration  pre- 
disposes to  a  return.  Permanent  cures  take  place  without  any  obliteration 
of  the  sac,  as  is  illustrated  by  the  rare  instances  of  cui-e  that  follow  simple 
tapping.  The  presence  of  limited  hydrocele  at  any  part  of  the  sac  or  cord 
can  be  treated  safely  and  successfully  by  the  preceding  means,  provided  vigi- 
lant diagnostic  discrimination  and  proper  surgical  technique  be  exercised. 

The  Results. — Aseptic  incision,  with  packing  of  the  sac,  or  flushing  or 
swabbing  the  cavity  with  an  irritant,  is  productive  of  better  results  and  with 
no  more  danger  than  is  injection.  The  patients,  however,  recover  more 
slowly  and  are  confined  longer  in  bed. 

The  Choice  of  Operation. — Kadical  cure  by  irritant  injections  should  not 
be  practiced  in  instances  in  which  the  hydrocele  may  be  dependent  on  local 
or  general  disease,  or  be  complicated  with  an  illy  defined  or  congenital  hernia, 
or  severe  pain  and  extreme  old  age.  The  presence  of  multiple  cysts,  or  a 
huge  one,  and  repeated  failures  by  this  method  or  the  fear  of  poisoning 
(carbolic),  forbid  its  employment.  Therefore,  treatment  by  palliative  tap- 
ping or  some  form  of  radical  incision  should  be  employed  in  these  classes  of 
cases.  If  the  hydrocele  be  congenital,  an  incision  similar  to  that  for  the 
radical  cure  of  hernia  may  be  required  for  cure. 

Castration. — Castration  is  ordinarily  a  simple  operation,  and  practically 
devoid  of  danger  to  the  patient  except  in  special  cases. 

After  the  pubes,  scrotum,  and  perinaium  are  shaved  and  thoroughly 
cleansed  with  soap  and  antiseptic  solutions  and  the  penis  incased  in  gauze, 
place  the  patient  on  the  back,  introduce  a  large  sponge  below  the  testicles 
between  the  thighs  to  collect  the  fluids,  and  administer  the  aufesthetic. 

The  Operation. — Seize  the  testicle  with  the  left  hand  and  draw  the 
scrotal  tissues  equally  and  tightly  over  it ;  make  an  incision  from  just  below 
the  external  abdominal  ring  downward  to  the  lower  limit  of  the  scrotum 
through  the  tissues  down  to  the  cord  and  tunica  vaginalis,  arresting  haem- 
orrhage as  it  occurs.  The  testicle  can  now  be  removed  along  with  the  uncut 
tunic  and  with  the  cord  by  enucleation  with  the  fingers  or  a  dull  instru- 
ment. In  doubtful  cases  it  is  better  to  open  the  sac  in  order  to  scruti- 
nize the  testicle  and  judge  if  it  be  necessary  after  all  that  it  be  removed. 
Although  an  additional  risk  of  infection  is  thus  incurred,  the  possible  gain 
to  the  patient  and  the  readiness  with  Vv-hich  it  may  be  enucleated,  the  same 
as  before,  wisely  sanctions  the  step.  If  the  testicle  and  the  visceral  layer  of 
the  tunic  only  are  to  be  removed,  the  parietal  part  of  the  tunic  is  severed 
around  the  testicle  as  closely  to  it  as  possible  with  scissors.  In  the  event  of 
the  removal  of  the  organ,  the  cord  is  isolated  with  the  finger  to  the  upper 
limit  of  the  incision  (Fig.  1430),  drawn  down  somewhat  out  of  the  ring. 


OPKUATION'S   UN    TllK   SCitOTlM    AND    I'KNIS. 


21 


clamped  only  sunicu'iitly  ti,i,'ht  to  control  liaMiion-hajifc,  uiul  cut  olT  about  hull" 
an  inch  below  the  point  of  seizure.  'I'he  three  arteries  of  the  cord  (Fig.  H.")!) 
lire  each  tied  independently  with  catgut.  Tiie  veins  also  should  be  tied.  The 
outer  surface  of  the  cord  is  then  seized  at  either  side  with  forcii)ressure  to 
prevent  its  undue  retraction  and  to  })rovide  the  means  of  withdrawal  from  the 
ring  if  luvmorrhage  happen  after  removal  of  the  clamp.  Remove  the  clamp, 
examine  the  stump  for  bleeding,  and,  if  none  be  present,  remove  the  forci- 
pressure  and  permit  the  cord  to  retract.  The  borders  of  the  wound  are  now 
brought  together  accurately  and  stitched  with  catgut  or  silkworm  gut,  leav- 
inj;  room  below  for  the  introduction  of  draiiuijije  if  needed.  If  the  need  of 
removal  of  the  sac  and  testicle  be  self-evident,  it  can  be  readily  accomplished 
without  exploration  by  ex})()sing  above  the  cord  through  a  free  incision  and 
separating  the  tissues  downward  along  the  cord,  ])ushing  the  tunic  and  the 
testicle  upward  through  the  incision.  This  course  limits  the  extent  of  the 
cutaneous  wound  and  correspondingly  lessens  the  extent  of  the  sewing,  dan- 
gers of  infection,  etc.  If  the  bottom  of  the  scrotum  be  buttonlioled,  ample 
opportunity  for  the  establishment  of  drainage  requirements  is  afforded.  The 
cord  is  treated  the  same  as  in  the  preceding  instance  and  the  incision  closed 
by  sewing. 

Tlie  Remarlis. — If  the  scrotal  integument  be  involved,  an  eliminating 
elliptical  incision  should  bo  made  (Fig.  1430).  Redundant  integument 
should  be  removed 
if  much  relaxed  or  of 
exceeding  amount. 
If  the  disease  be  non- 
infective,  the  inci- 
sion may  be  made  as 
brief  as  possible.  If 
a  hernia  be  present, 
a  radical  cure  can  be 
performed  at  the 
same  time  if  not  con- 
tra-indicated. 

The  Precautions. 
— Care  should  be  ex- 
ercised to  detect  the 
presence  of  a  hernia 
at  the  seat  of  opera- 
tion, for  apparent  reasons.  In  malignant  disease  tlie  lymph  nodes  directly 
associated  with  it  should  be  removed,  whether  enlarged  or  not.  Cauteriza- 
tion of  the  end  of  the  vas  deferens  should  be  practiced  if  it  be  infected 
by  disease  extension.  The  incautious  division  of  an  overstretched  cord 
will  cause  the  stump  to  disappear  promptly  out  of  reach.  Therefore,  divi- 
sion of  the  cord  during  manual  or  tumor-weight  traction  should  be  carefully 
avoided.  Xeuralgia  and  secondary  luvmorrhage  may  follow  the  tying  of 
the  cord  en  masse  ;  the  former  may  arise  from  transfixion  of  the  cord.  High 
division  of  the  cord  should  be  practiced  in  the  instance  of  malignant  disease. 


Fig.  1430. — Tlic   operation   of  castration   with   involvement  of 
scrotal  tissue.     Penis  wrapped  in  aseptic  gauze. 


121G  OPERATIVE  SURGERY. 

In  non-infective  cases  it  may  be  tied  within  an  inch  or  so  of  the  testicle,  if 
feasible.  Retention  of  urine  sometimes  follows  castration,  and  the  liability 
of  its  occurrence  should  always  be  anticipated  and  provided  for.  Care 
should  be  exercised  in  uniting  the  borders  of  the  wound,  or  the  movements 
of  the  dartos  will  disarrange  the  coaptation.  The  writer  practices  the  intro- 
duction througli  the  borders  of  three  or  four  deep  sutures  for  the  purpose 
of  better  controlling  these  movements,  after  which  the  more  superficial 
sutures  are  applied  and  proper  adjustment  of  the  cut  borders  secured. 
Strong  lotions  should  not  be  used  in  washing  the  scrotum,  as  they  often 
cause  acute  suffering  and  severe  irritation. 

After-treatment. — The  wound  is  drained,  dressed,  and  attended  there- 
after in  the  manner  characteristic  of  aseptic  treatment.  When  employed, 
drainage  is  removed  at  the  first  dressing ;  the  sutures  at  the  end  of  the  first 
week.     Strapping  may  be  needed  to  complete  the  deep  healing  satisfactorily. 

The  Results. — The  danger  to  life  when  done  for  malignant  disease  is  about 
2  per  cent.  About  13  per  cent  remain  free  from  return  for  more  than  three 
years.    C!astration  is  employed  for  chronic  prostatic  enlargement  (page  1142), 

Orchidopexy. — Orchidopexy  relates  to  the  bringing  down  into  the  scro- 
tum and  retaining  of  an  incompletely  descended  testicle.  This  plan  is  not 
attempted  until  after  failure  of  sini})Ier  means  and  the  lapse  of  time  render 
operative  steps  advisable.  The  external  ring  is  exposed  through  a  free  inci- 
sion, which  is  extended  upward  or  downward,  as  circumstances  require,  to 
reach  the  testicle.  The  testicle  is  seized  and  drawn  downward,  while  the 
cremaster  muscle  and  other  unimportant  restraining  tissues  are  divided  by 
careful  dissection.  The  scrotal  structures  are  then  separated  by  blunt  dis- 
section so  as  to  form  a  suitable  nidus  for  the  deposit  of  the  organ,  after  which 
it  is  retained  in  position  by  wrapping  around  the  cord  between  the  external 
ring  and  the  testicle  the  contiguous  scrotal  folds  and  securing  them  in  place 
by  sutures.  The  successful  attainment  of  these  steps  is  not  as  easy  nor  finally 
as  satisfactory  as  might  appear  from  the  description.  Instrumental  restraint 
is  advised  after  the  operation  to  retain  the  organ  in  place  while  awaiting  the 
gain  arising  from  increasing  growth.  The  unsatisfactory  outcome  that  has 
so  often  followed  these  efforts  of  restoration  has  prompted  the  selection  by 
some  operators  of  other  means  of  treatment.  Dawbarn  advises  the  raising 
and  planting  of  the  testicle  so  deeply  beneath  the  tissues  at  the  internal 
aspect  of  the  inguinal  canal  that  it  will  be  removed  from  harm  and  also 
escape  the  dangers  attendant  on  scrotal  implantation. 

Dotvd,  with  the  view  of  gaining  as  much  as  possible  in  length  of  the 
cord,  shortened  its  course  by  division  of  "  the  transversalis  fascia  from  the 
internal  ring  downward  to  the  pubic  bone."  This  course  obviated  the 
restraining  influence  of  the  vas  deferens.  The  remaining  restraint  was  quite 
overcome  by  careful  division  of  the  cremaster  muscle,  supplemented  with 
gentle  traction  on  the  cord  and  testicle.  By  these  means  the  organ  could 
be  secured  below  the  pubic  bone  by  stitching  to  tlie  scrotum.  The  incision 
in  the  fascia  was  sutured,  and  after  healing  a  truss  was  worn  for  three  months 
to  prevent  retraction.  At  the  end  of  a  year  the  parts  were  in  their  normal 
relation. 


Ol'KliATIONS   ON    THK   SCKUTLM    AM)    I'L^NLS. 


1217 


The  lienutrk's. — li\  tlic  division  of  the  restriiining  tissues  of  the  cord, 
injury  to  the  vessels  and  nerves  and  the  vas  deferens  should  be  carefully 
avoided.  In  the  instances  in  which  tiie  undescended  testicle  is  functionally 
useless,  and  only  sentiment  urges  orchi(lo])exy,  the  removal  of  the  misplaced 
organ  and  the  introduction  of  a  false  one  into  the  scrotum  may  satisfy  the 
sensibility  of  the  ])atient,  and  relieve  him,  at  tlie  same  titiie,  of  the  annoy- 
ances and  dangers  from  the  imprisoned  organ. 

Circumcision. — Circumcision  is  practiced  when  phimosis  or  an  uncompli- 
cated redundancy  of  the  foreskin  exists,  to  relieve  the  patient's  pain  and 
annoyance  from  these  conditions.     The  patient  is  placed  on  the  back,  and 


-„ii„„iiiiiiMMiiiiiiiiiiiiiiiiiiiiiiir: 


mm 


Fiu.  1431. — Henry's  phimosis  forceps. 


Fig.  1432. — Fisher's  {phimosis  forceps, 

general  or  local  anaesthesia  administered.  The  object  of  the  operation  is  not 
to  remove  the  foreskin  so  as  to  leave  the  entire  glans  penis  exposed  after 
recovery,  but  to  allow  sufficient  integument  to  remain  to  afford  the  protec- 
tion characteristic  of  the  normal  prepuce.  The  situation  of  the  base  and 
apex  of  the  glans  should  be  determined,  and  with  a  pen  or  pencil  an  oblique 
line  is  drawn  corresponding  to  the  direction  of  the  base  of  the  glans,  about 
midway  between  it  and  the  apex,  upon  the  integument  (Fig.  1439).  The 
foreskin  is  then  drawn  downward,  placed  between  the  blades  of  the  clamp 
(Figs.  1431  and  1432),  with  the  line  just  made  corresponding  to  the  lower 
border  of  the  blades,  care  being 
taken  not  to  include  the  glans  in 
the  grasp  (Fig.  1433).  The  clamp 
is  tightened,  and  the  distal  por- 
tion severed  by  a  scalpel  or  scis- 
sors (Fig.  1434).  The  clamp  is 
then  removed  (Fig.  1435),  when 
the  integument  retracts  to  or  a 
little  behind  its  previous  location 
{a).  The  mucous  membrane, 
which  still  covers  the  glans,  is 
slit  up  on  a  grooved  director,  along 
the  dorsum  to  the  corona  {h),  and 
trimmed  symmetrically  on  either 

side,  not  even  with  the  integument  (c),  but  near  enough  to  it  so  that  when 
it  is  turned  over  and  its  free  borders  are  stitched  to  the  skin,  a  vermilion 
border  (rZ),  at  least  a  third  of  an  inch  wide,  is  formed.     Before  the  sew- 


FiG.  1433.— t'lainping  foresi<in. 


1218 


OPERATIVE   SURGERY. 


ing  is  done,  the  mucous  membrane  should  be  stripped  off  the  glans  to  a 
point  behind  the  corona,  all  smegma  removed,  and  the  part  cleansed,  after 


Fui.  14:J4. — Taylor's  phimosis  scissors. 

which   the  mucous  sleeve   is   returned  to  place,  and  its  border   joined    to 
that  of  the  integument  by  an  interrupted  or  continuous  fine  catgut  suture. 

If  the  mucous  membrane  grasp  the  glans 
too  tightly,  thus  predisposing  to  the  occur- 
rence of  paraphimosis,  it  must  be  slit  on 
the  dorsal  surface  up  to  its  point  of  reflec- 
tion, after  which  the  borders  are  joined  as 
before  described.  The  final  division  of  the 
membrane  at  the  dorsum  will  permit  the 
prepuce  to  accommodate  itself  to  the  vary- 
ing dimensions  of  the  penis  that  occur  not 
infrequently  during  the  process  of  healing. 
Keyes's  Method. — Keyes's  method  is  an  admirable  one  (Fig.  1436),  and 
is  intended  to  meet  the  same  reparative  indications  as  the  preceding.  In 
this  the  mucous  membrane  is  not  slit  up,  but  both  it  and  the  integument 
are  shaped  to  correspond  to  the  outlines  «,  b,  c  and  d,  e,  /,  respectively, 
after  which  the  former  flap  is  reflected  backward  and  joined  to  the  integu- 
ment, so  that  b  shall  correspond  to  e,  a  to  d,  and  c  to  f.  This  plan  does 
not,  however,  insure  the  same  freedom  from  constric- 
tion as  does  the  long  dorsal  slit  just  described.  If  the 
phimosis  be  not  attended  by  an  elongation  of  the  fore- 
skin, a  cure  may  be  effected  by  slitting  up  the  dorsal 


Fig.  1435. — Steps  of  circumcision. 


Fig.  1436.— Keyes's 

modification. 


Fig.  14:37.— Dorsal 
slit. 


Fig.  1438. — Trimming   foreskin 


surface  on  a  director  to  the  base  of  the  glans  (Fig.  1437).  The  earlike  pro- 
jections on  either  side  are  then  trimmed  off  (Fig.  1438),  and  the  mucous 
and  cutaneous  borders  stitched  to  each  other  with  catgut.     Roser''s  trian- 


()IM;i{.\'ri()NS    ON    'I'lIK   SCKO'I'I'.M    AM)    I'KMS. 


\-2V.) 


giiltir-tliip  iiiethoil  is  ousily  perfoniu'd  ami  of  stM'vict'ablo  outcome,  A  dor- 
siil  division  of  tiie  propueo  is  niado  with  scissors  or  a  director  and  pointed 
scalj)('l.  After  the  division  tlic  outer  hiyer  of  the  jorepuce  retracts  more 
than  tiie  inner  (Fig.  HiJD).  The  inner  layer  is  then  divided  at  either  side 
obliquely  outward  to  the  border  of  the  glans,  and  the  small  triangular  flap 
thus  formed  above  is  turned  over  into  the  angle  formed  by  division  of  the 
outer  layer  and  sutured  in  place.  After  suitable  trimming  of  the  earlike 
angles  of  the  outer  layer,  the  corresponding  borders  of  the  two  layers  are 
sutured  together.  (JuJIcrrivr,  after  thorough  cleansing  of  the  subpreputial 
space,  accom])lished  well  the  purj)ose  in  this  condition  by  subcutaneously 
dividing  the  mucous  membrane  in  three  or  four  places  by  means  of  blunt- 
pointed  scissors;  the  blunt  point  resting  upon  the  glans,  while  the  sharp 
one  was  passed  between  the  membrane  and  the  integument.  If  the  prepuce 
be  short,  and  the  case  not  an  aggravated  one,  the  mucous  lining  may  be 
stretched.,  and  even  torn  asunder,  by  introducing  the 
blades  of  dressing  forceps  between  the  glans  and 
foreskin  and  expanding  them,  after  which  the  fore- 
skin is  drawn  backward  and  retained  until  healing 
is  completed. 

Tlte  Pr('C((utions. — If  too  much  tissue  be  left  at 
the  frenum,  a  disfigurement  follows  of  annoying  dura- 
tion. If  forcible  traction  be  made  on  the  foreskin 
before  its  severance,  the  integumentary  portion  will 
be  made  much  too  short.  If  the  foreskin  be  adhe- 
rent to  the  glans,  and  the  preputial  orifice  be  small,  pig.  i439._Roser's  opera- 
the  grooved  director  may  be  carried  into  the  urethra  tion  for  phimosis,  a. 
and  the  glans  divided.  If  commendable  cleanliness 
be  not  exercised  in  this  operation  and  maintained  in 
the  treatment,  troublesome  cellulitis  may  follow. 
The  doctrinal  method  of  practice  is  sometimes  fol- 
lowed by  this  complication. 

The  Remarks.— YiwQ  catgut,  continuous  or  interrupted  sutures,  should 
be  employed  in  sewing,  and  the  stitches  should  be  placed  as  near  to  the  bor- 
ders as  possible,  so  that  they  will  cut  their  way  out  without  pain  or  disfigure- 
ment, thus  forestalling  the  annoyance  of  removal.  Horsehair  is  sometimes 
used  in  sewing  the  borders  together.  Only  trifling  haemorrhage  occurs 
in  adults ;  in  infants  scarcely  any.  Sometimes  in  infants  the  tissues  are 
permitted  to  heal  without  suturing ;  and  often,  too,  in  infants  the  dorsal 
slit  completes  the  operation. 

The  After-treatinenf.— The  after-treatment  in  all  the  methods  of  opera- 
tion is  directed  to  modifying  the  inflammation,  preventing  the  occurrence 
of  erection  of  the  penis,  and  keeping  the  parts  clean. 

The  wound  is  dressed  at  first  by  surrounding  it  with  a  narrow  piece  of 
dry  aseptic  iodoformized  gauze  drawn  closely  in  place  and  carried  upward 
so  as  to  cover  the  entire  organ.  After  a  day  or  so  this  dressing  can  be 
soaked  off  by  placing  the  patient  in  a  warm  tub  bath  or  by  gentle  irrigation 
with  warm  sterilized  water,  followed  by  the  same  treatment  as  often  as  clean- 
83 


Inner  layer  of  the  pre- 
puce, b.  Cut  edge  of 
the  outer  hiyer.  c. 
Triangular  flap  formed 
from  the  inner  layer  by 
two  oblique  incisions. 


1220 


OPERATIVE  SURGERY. 


liness  aud  comfort  require.  The  penis  should  be  supported  by  a  textile 
fabric  ring  within  which  it  rests,  and  the  clothes  should  not  be  permitted  to 
come  in  contact  with  the  sensitive  glans.  A  capacious  cradle  interposed 
for  this  purpose  meets  the  indication  and  at  the  same  time  affords  good 
ventilation.  All  constriction  of  the  organ  should  be  prevented,  to  obviate 
the  (cdema  of  the  parts  which  will  surely  follow.  In  the  adult  a  cold-water 
rubber  coil  carried  around  the  penis  may  prevent  erection  and  the  pain  and 
tearing  of  the  tissues  incident  to  this  happening.  The  application  of  oleagi- 
nous substances  should  be  limited  to  the  glans  and  borders  of  the  dressing 
exposed  to  wetting  with  urine.  The  application  of  collodion  to  the  borders 
of  the  wound  is  objectionable  on  account  of  the  contraction  attending  fixa- 
tion. If  stitch  irritation  does  not  take  place,  the  stitches  may  remain  until 
released  by  absorption.  Troublesome  erections  may  be  palliated,  if  not  pre- 
vented, by  the  use  of  cold,  dry  applications. 

In  one  case  we  now  recall,  local  and  general  medication  combined  were 
not  sufficient  to  control  or  hardly  mitigate  the  tendency  to  erections ;  how- 
ever, the  complication  was  effectually  met  by  employing  a  nurse  to  watch 
the  organ  wiiile  the  patient  slept,  with  instructions  to  awaken  him  on  the 
appearance  of  the  first  indication  of  an  erection. 

The  Results. — The  danger  to  life  or  to  the  integrity  of  the  organ  is 
scarcely  entitled  to  the  dignity  of  mention  if  aseptic  measures  be  practiced 
throughout.  If  healing  by  granulation  takes  place,  or  the  operative  tech- 
nique be  faulty,  the  preputial  opening  may  become  too  small  and  l)e  rigid 
and  unyielding. 

Paraphimosis  (Fig.  1440). — In  paraphimosis  the  foreskin  is  firmly  lodged 
behind  the  corona  glandis,  so  as  to  cause  great  congestion,  osdema,  and  slough- 
ing of  the  parts  if  not  relieved 
(P'ig.  1441),  and  the  condition 
may  even  terminate  in  gangrene 
and  sloughing.  The  reduction 
of  the  foreskin  may  be  accom- 
plished in  the  following  manner: 
Oil  the  parts  well,  and  ad- 
minister an  aneesthetic  if  neces- 
sary ;  grasp  the  penis  behind 
the  constriction  with  the  thumb 
and  fingers  of  the  left  hand, 
and  the  glans  with  the  tips  of 
the  thumb  and  fingers  of  the 
right ;  press  the  glans  with  the 
latter  gradually  to  reduce  the 
swelling,  then  draw  the  constriction  forward  with  the  left,  while  the  glans 
is  gradually  forced  through  it  with  the  thumb  and  fingers  of  the  right  (Fig. 
1442).  If  the  constriction  be  not  great,  and  the  cedema  and  congestion  be 
moderate,  this  manipulation  will  soon  effect  the  reduction.  In  all  cases 
where  much  oedema  exists,  acupuncture  should  be  performed,  and  the  fluids 
squeezed  through  the  openings  before  reduction  is  attempted.     When  the 


Fig.  1440. 
Paraphimosis. 


Fig.  1441.— Results  of 
the  constriction. 


uriOKATlONS   UN   THH   SCllUTLM    AND    i'ENIS. 


1221 


part  is  corrii^jitfd  iiiitl   imifli  .swolloii  by  loiiff-stiiiuliii^'  suvcrc  con.strictious, 

followed  by  iiillamiiiuliuu  and  {)laslic  (I'duiiia,  and  perliaps  by  incipient  gan- 

,,, .  ,,,,,,,  grene,  it  will  be  necessary  to  sever  the  con- 

(**'    "  striction  freely  on  the  dorsal  surface  by  a 

^,      ,  I  sharp-})ointt'd,  curved  bistoury  (Fig.  1443), 

li^"  "\J^>  Oihcr   methods  of  grasping  the  penis  are 

y  ^Jk    ^  reconiniended  to  effect  the  reduction  of  the 

foreskin  (Figs.  1444  and  1445). 


Fui.  1442. — Paraphimosis.   First  meth-    Fig,  1443. — Slitting  up  the  constriction  on   a 
od  of  reduftion.  grooved  director. 

T/ie  Comments. — The  employment  of  sjiecially  devised  instruments  to 
compress  the  distended  glans  is  a  refinement  of  needless  birth.  The  elimi- 
nation of  oedema  by  acupuncture  followed  by  elevation  of  the  organ  and  by 
hot,  soothing  applications,  will  very  often  prepare  the  way  to  prompt  reduc- 
tion. However,  if  impending  sloughing  be  noticeable,  free  and  prompt 
division  of  the  constriction,  followed  by  the  palliative  measures,  will  secure 
the  promptest  and  most  satisfactory  results. 

After-treatment. — Following  reduction, 
thoroughly  cleanse  and  disinfect  the  parts; 


Fig.  1444.— Paraphimosis.   Second  meth-    Fig.  144.5— Paraphimosis.     Third  meth- 
od of  reduction.  od  of  reduction. 

place  the  patient  in  bed,  with  the  penis  elevated  and  supported,  and  dress 
with  soothing  antiseptic  lotions. 


1222 


OPERATIVE  SURGERY. 


Amputation  of  the  Penis. — Amputation  of  the  penis  is  commonly  prac- 
ticed for  the  purpose  of  removal  of  nuilignant  disease. 

TJie  A}iatomical  Points. — The  organ  is  abundantly  supplied  with  blood- 
vessels and  lymphatics,  and  well  suited,  therefore,  to  malignant  spread  from 
the  anatomical  standpoint.     The  arrangement  and  relations  to  each  other  of 


d     e  'd 

Fig.  1446. — Cross  section  of  the  penis.  A,  in  flaccid,  B,  in  erect  condition,  a.  Dorsal 
veins  and  artery  of  penis,  h.  Network  of  corpus  cavernosum.  c.  Sliin  of  penis. 
d,  Network  of  corpus  spongiosum,     e.   Urethra. 

the  important  vessels  and  structures  is  better  shown  by  the  illustration  (Fig. 
1446)  than  words  can  depict. 

Prepare  the  sound  portion  of  the  penis,  the  pubes,  and  scrotum  for  oper- 
ation by  aseptic  measures ;  cleanse  and  surround  the  diseased  portion  with 
antiseptic  gauze ;  empty  the  bladder,  place  the  patient  on  the  back  and 
administer  an  anaesthetic. 

The  Operation. — Introduce  a  sound  into  the  urethra  and  give  it  in  charge 
of  an  assistant ;  pass  the  rubber  band  firmly  twice  around  the  base  of  the 
penis  and  clamp  or  tie  the  ends,  to  control  the  circulation  (Fig.  1449) ;  hold 
the  penis  lightly  and  conveniently  with  the  hand  ;  divide  the  integument  with 
a  circular  cut  around  the  penis  with  a  scalpel ;  divide  the  corpora  cavernosa 
vertically  down  to  the  corpus  spongiosum  ;  isolate  the  corpus  spongiosum 
forward  for  an  inch ;  remove  the  sound  and  cut  off  the  spongy  body  at  the 
anterior  limit  of  exposure ;  tie  the  open  mouths  of  the  vessels  and  remove 
the  rubber  constriction ;  arrest  further  bleeding  and  slit  up  the  urethra  for 
three  fourths  of  an  inch  at  the  lower  surface  and  turn  up  the  resulting  flap ; 
snip  off  the  angles  at  the  upper  border  and  join  the  margins  of  the  urethral 
flap  to  the  integumentary  with  fine  interrupted  catgut  sutures,  being  espe- 
cially careful  to  get  good  juxtaposition  below  to  prevent  urinary  infiltration ; 
draw  the  integument  backward  so  as  to  bring  the  flaps  in  firm  contact  with 
the  divided  ends  of  the  corpora  cavernosa,  putting  a  catgut  suture  deeply 
through  at  either  side  to  hold  them  in  place ;  introduce  a  soft-rubber  cathe- 
ter into  the  bladder,  clamp  the  end  and  fasten  it  there  ;  surround  the  stump 
of  the  penis  with  aseptic  gauze  held  firmly  in  place  with  the  catheter  pro- 
truding through  it,  and  fastened  in  position ;  support  the  scrotum  and  the 
dressing  with  an  apron  or  T-bandage ;  attach  to  the  catheter  a  small  rubber 
tube,  causing  it  to  pass  beneath  the  surface  of  an  antiseptic  fluid  contained 
in  a  vessel  placed  (Fig.  1315)  beneath  the  bed.  The  dressing  is  changed 
when  soiled   and  a  fresh  dressing  applied.     The  cases  thus  far  treated  in 


Ol'KKATlONS   ON    'IMII']   SCROTL'M    AND    I'KNIS. 


1223 


this  inaiiner  by  the  writer  have  healed  promptly  by  lirst  intention,  and  the 
dressinif  has  been  dispensed  with  in  a  week's  time.  Treves  advises  that  the 
urethra  be  slit  along  tlie  dorsum,  turiie(l  down,  and  the  lower  end  stitched 
to  the  integument  below,  whieh  is  made  longer  for  this  purpose.  The  sides 
of  the  Hap  are  sutureil  to  the  eori)ora  cavernosa.  The  mode  of  dressing  is 
substantially  the  same,  and  in  both  instances  the  skin  turns  inward  and 
forms  a  puckered  prepuce  at  the  end  of  the  stump. 

The  Flap  Method  of  Amputation. — An  excellent  stum{)  and  raj)id  heal- 
ing follow  this  method.  After  the  proper  control  of  the  vessels,  extend  the 
penis  gently  and  enter  a  narrow-bladed  knife  at  a  point  well  removed  from 
the  disease,  between  the  corpus  spongiosum  and  the  corpora  cavernosa,  and 
cut  forward  and  downward  through  the  tissues,  making  a  flap  about  three 
fourths  of  an  inch  in  length,  from  which  tlie  urethra  is  then  dissected. 
Make  a  long  oval-shaped  flap  from  the  dorsum  and  sides  of  the  penis  of 
much  greater  length  than  that  of  the  first ;  reflect  the  flap  back  and  divide 
the  corpora  cavernosa  vertically  downward  to  the  point  of  transfixion  (Fig. 
1447) ;  remove  the  rubber  constriction  ;  secure  the  bleeding  points ;  punc- 
ture the  upper  flap  at  the  middle ;  carry  the  urethra  through  the  opening 
and  sew  its  extremity  to  the  edge  of  the  slit  and  the  borders  of  the  flaps  to 


Fk;.  1447. — Anipiitation  of  penis.  Long 
superior  ovai-siuiped  flap.  Short  in- 
ferior flap. 


Fig.   1448. — Amputation  of  penis.     Flaps 
united  and  urethral  opening  fixed. 


each  other  with  catgut  (Fig.  1448).  Introduce  the  catheter  and  dress  and 
treat  as  in  the  preceding  method. 

Hilton  modified  the  operation  by  dividing  the  spongy  body  about  a  fourth 
of  an  inch  in  front  of  the  cavernous  portion,  splitting  it  longitudinally,  and 
uniting  the  lateral  flaps  thus  formed  to  the  integument. 

Humphreif  turns  back  from  the  integument  of  the  penis  a  circular  flap 
about  half  an  inch  in  length,  divides  the  corpora  cavernosa  on  a  level  with 
the  attachment  of  the  flap,  and  cuts  the  spongy  body  at  least  half  an  inch 
longer  than  the  cavernous  bodies,  and  attaches  the  integument  to  its  ex- 
tremity. 

An  old  method  of  practice,  now  rarely  employed,  consists  in  transverse 
division  of  the  organ  (Fig.  1449,  «),  followed  by  suture  of  the  borders  of  the 
divided  end  of  the  urethra  {h)  to  those  of  the  severed  integument  (c).  A 
catheter  is  introduced  into  the  urethra,  and  the  raw  surfaces  are  carefully 
apposed  to  each  other  by  means  of  suitable  dressings. 


1224 


OPERATIVE   SURGERY. 


Thiersch  amputated  the  penis  at  the  j^ubes,  split  the  scrotum,  divided 
longitudinally  the  corpus  spongiosum  the  distance  of  an  inch,  and  brought 
the  free  end  of  the  urethra  out  of  a  wound  made  in  the  perinaeum  an  inch 
and  a  half  in  front  of  the  anus,  to  the  borders  of  which  the  extremity  of  the 
urethra  was  stitched. 

Dnvies-Colly  amputated  the  penis  at  the  scrotum ;  then,  through  an  inci- 
sion made  into  the  posterior  scrotal  rhaphe  down  upon  the  urethra,  he  iso- 
lated the  corpus  spongiosum,  brought  the  divided  extremity  out  through  the 
opening,  and  stitched  its  borders  to  those  of  the  incision. 

The  Precautions. — If  the  amputation  is  to  be  made  close  to  the  sym- 
physis, retraction  of  the  stump  and  infiltration  of  the  scrotum  with  urine 
must  be  guarded  against.  If  a  stout  ligature  be  passed  through  the  fibrous 
sheath  of  the  penis,  a  little  above  the  point  of  proposed  section,  the  stump  can 
be  controlled  and  the  first  accident,  and  possibly  the  second,  will  be  obviated 
by  this  means.  At  all  events,  the  infiltration  can  be  prevented  by  dividing 
partly  or  entirely  through  the  scrotum  and  the  floor  of  the  urethra,  in  the 


Fig.  1449. — Amputation  of  penis  by  transverse  division,  a.  Act  of  amputating  organ 
constricted  with  rubber  tube.  h.  End  of  stump,  showing  vessels,  urethra,  and  cavern- 
ous bodies,     c.  Integument  united  to  urethra. 


line  of  the  urinary  canal,  and  uniting  the  borders  of  the  integument  to  those 
of  the  urethra  so  as  to  form  two  scrotums  (Fig.  1450  ),  with  the  urinary 
opening  between  them.  A  disarrangement  of  the  drainage  or  withdrawal  of 
the  catheter  by  traction  on  the  tube  often  leads  to  prompt  saturation  of 
the  dressings.  If  the  patient  be  intractable  in  this  respect,  the  catheter  is 
employed  every  four  or  five  hours,  and  it  may  be  withdrawn  entirely  or  only 
partially  after  each  introduction,  as  may  be  deemed  essential.  If  complete 
withdrawal  be  practiced,  a  long  silkworm-gut  suture  should  be  stitched  at  the 


OPERATIONS  ON   THE   SCKOTLM    AND    I'KNIS. 


122; 


N 


'% 


Fig.  1450. — Anipiitai  ion  of  penis  close  to  sero- 
tiiin.  The  latter  .split  and  divided  bor- 
ders sewed  together,  inclosing  testicles. 


outset  to  tlie  floor  of  the  iirethrti  a.s  a  guide  to  the  o{)oiiiii<f.  lufiitriition  of 
urine  between  the  flaps  shouKl  be  stii(liou.sly  Jiv(jided.  If  the  line  of  junction 
be  smeared  witii  iodoforniized  vaseline  with  each  dressing,  the  liability  to  this 
complication  i.s  considerably  les.sened.  The  lymphatic  nodes  in  the  line  of 
the  lymph  How  of  the  penis,  whether 
enlarged  or  not,  should  be  sought 
for  and  removed  at  once  in  malig- 
nant disease.  In  every  case  careful 
stated  periodical  surveillance  should 
be  exercised  after  operation,  in  order 
to  detect  and  eliminate  the  earliest 
manifestations  of  lymphatic  involve- 
ment or  disease  recurrence.  It  is 
wise,  too,  to  subject  the  lymph  nodes 
to  microscopical  examination,  to 
determine  in  them  the  presence  of 
malignant  processes. 

The  Eeviarks. — The  scrotum  and 
the  wound  should  be  kept  clean,  and 
the  former  frequently  anointed  with 
vaseline  to  prevent  irritation.  If  repair  by  granulation  takes  place,  a  struc- 
tural narrowing  of  the  opening  may  follow.  Transfixion  sidewise  of  the 
corpora  cavernosa  with  a  long  needle,  and  application  of  the  constricting 
agent  behind  it,  is  advisable  if  a  short  stump  is  to  be  formed,  as  then  the  lat- 
ter is  better  controlled  and  prevented  from  retracting  into  the  soft  parts. 
Do  not  amputate  within  tliree  fourths  of  an  inch  of  the  disease,  if  avoidable. 
Extirpation  of  the  Penis — Extirjiation  of  the  penis  is  practiced  only 
when  the  disease  is  extensive  and  no  complications  are  j^resent  that  forbid 
the  operative  technique. 

The  Operation  (Gould). — Cleanse  the  parts  thorouglily  ;  place  the  patient 
in  the  lithotomy  position ;  incise  the  scrotum  in  the  median  line  the  entire 
length  of  the  rhaphe  ;  separate  the  scrotum  into  halves  (Fig.  1450)  quite  down 
to  the  corpus  spongiosum  with  the  finger  and  handle  of  the  scalpel ;  intro- 
duce into  the  urethra,  down  to  the  triangular  ligament,  a  full-sized  sound  or 
catheter ;  insert  a  long,  thin-bladed  knife  transversely  between  the  corpus 
spongiosum  and  the  corpora  cavernosa;  withdraw  the  instrument  from  the 
urethra;  sever  the  urethra  at  the  pubes  and  detach  it  backward  to  the  trian- 
gular ligament ;  make  an  incision  around  the  root  of  the  penis  continuous 
with  the  one  in  the  median  line ;  divide  the  suspensory  ligament  and  sepa- 
rate the  penis,  except  at  the  attachment  of  the  crura,  with  a  scalpel ;  discon- 
nect each  crus  from  the  pubic  arch  with  a  periosteal  elevator ;  ligature  the 
bleeding  vessels  ;  slit  up  the  corpus  spongiosum  for  about  half  an  inch ;  raise 
the  edges  of  the  divided  urethra  and  stitch  them  to  the  back  part  of  the 
scrotal  incision  ;  close  the  remainder  of  the  scrotal  incision  with  sutures, 
and  establish  through-and-through  drainage  in  the  deep  part  of  the  wound. 
A  catheter  is  not  used.     The  wound  is  cleansed  and  dressed  in  the  usual 


1226 


OPERATIVE   SURGERY. 


The  Remarks. — Extensive  glandular  involvement  and  enfeebled  repara- 
tive power  contraindicate  the  operation. 

Gouley's  Method. — In  Gouley's  method  make  a  curvilinear  incision  at 
either  side  of  the  root  of  the  penis,  beginning  in  the  median  line,  about 
an  inch  and  a  half  above  the  level  of  the  pubes  and  ending  a  little  below 
the  peno-scrotal  junction.  The  cavernous  bodies  are  exposed  and  transfixed 
with  a  large  knitting  needle  or  with  a  suitable  substitute ;  the  urethra  is 
transfixed  by  a  smaller  instrument  of  like  nature  on  the  same  plane,  and  the 
penis  is  amputated  an  eighth  of  an  inch  in  front  of  them.  After  all  the 
bleeding  points  are  secured,  a  grooved  staff  is  introduced  through  the  urethra 


Fig.  1451. — The  vessels  of  left  testis  and 
cord  (outer  surface),  a,  a.  Spermatic 
artery.  b.  Anterior  spermatic  veins 
surrounding  artery,  c,  I,  i.  Head,  body, 
and  tail  of  epididymus.  d.  Anterior 
extremity  of  (with  hydatid  of  Morgagni), 
e,g,  antero-inferior  surface  of,  /,  out- 
er surface  of,  h,  postero-superior  sur- 
face of,  and  h,  postero-inferior  extrem- 
ity of  testicle.  ,/,./,,/.  Vas  deferens  and 
its  artery,   m.  Posterior  spermatic  veins. 


Fig.  1452. — The  vessels  of  left  testis  and 
cord  (inner  surface),  a,  a.  Vas  deferens 
and  its  artery,  b.  Posterior  spermatic 
veins,  c,  h.  Tail  and  head  of  epididy- 
mus. g.  Anterior  extremity  of  testis 
and  hydatid  of  Morgagni.  /.  Inner,  e, 
antero-inferior,  d,  postero-inferior  sur- 
faces of  testis,  i,  i.  Spermatic  artery. 
j.  Anterior  spermatic  veins  surround- 
ing artery. 


into  the  bladder.  A  sharp-pointed  scalpel  is  then  carried  through  the  peri- 
naeum  and  lodged  in  the  grooved  staff,  and  all  the  tissues,  including  the 
scrotum,  are  divided  from  behind  forward.     The  urethral  cut  is  about  an 


OPERATIONS   ON   TIIK   SCROTUM    AND    I'KNIS. 


122: 


inch  iind  ;i  Imlf  in  Iciii^th,  and  the  cutaneous  one  three  inches.  'I'he  urethra 
is  now  detached  from  the  cavei-nous  Ijodies,  whicli,  toj^'ether  with  their  crura, 
are  dissected  away,  after  wliich  the  horders  of  the  ui'ethra  are  united  to  tliose 
of  tile  perineal  wound.  Tlie  testicles  are  inclosed  so})a- 
rately  in  the  scrotal  tissues  at  eitlier  side  of  the  peri- 
neal incision,  hy  sewin":,^  together  their  divided  hor- 
ders (Fig.  UoO). 

The  licsuUs. — Bidlin  reports  53  cases  of   simple 

amputation  with  one  death.     In  extirpation  the  rate 

1453  —Transverse  ^'^  ^^t)ut  G  per  cent.     Of  G5  cases  23  had  passed  suc- 

section    of    conl    at  cessfully  the  three-year  limit.     Urination  is  quite  well 

left    abdominal    rini 


a.  Crcinaster   muscle. 

b.  Cremasteric  vessels. 

c.  Spermatic     artery. 

d.  e.  Vessels  of  the 
vas  deferens.  /.  Vas 
deferens.  (/.  Pam- 
piniform plexus,  i.e., 
spermatic  veins. 


done  and  intercourse  may  he  fruitful  ex(;ept  in  cases 
of  extirpation. 

Varicocele. — Varicocele  is  a  term  ai)plied  to  a  vari- 
cose state  of  the  veins  of  the  spermatic  cord.  The 
veins  here,  as  in  other  parts  of  the  body,  may  be  little 
or  much  distended,  calling,  therefore,  for  either  the 
palliative  or  radical  method  of  treatment. 
The  Anatomical  Points. — The  vas  deferens,  the  three  arteries,  and  the  two 
sets  of  veins  constitute  the  most  important  structures  of  the  cord.  The  vas 
deferens  is  a  round,  white,  firm,  incompressible  structure,  an  eighth  of  an 
inch  in  diameter,  easily  recognized,  as  it  lies  at  the  posterior  aspect  of  the 
spermatic  cord.  The  spermatic  artery  lies  in  front  and  (Figs.  1451  and 
1452)  the  artery  of  the  vas  at  the  side  of  the  vas  deferens,  and  the  cremasteric 
artery  among  the  superficial  layers  of  the  cord  at  the  outer  side.  The  sper- 
matic veins  and  those  of  the  vas  run  upward,  the  former  being  the  larger, 
the  more  numerous,  and  lying  in  front;  the  latter  the  smaller,  and  attendant 
on  the  vas  deferens.  The  veins  of  the  left  are  larger  than  those  of  the  right 
side,  and  usually  the  spermatic  veins  of  either  side  are  affected  much  oftener 
than  are  those  of  the  vas  deferens.  An  abundance  of  connective  tissue  is 
present  between  the  structures  of  the  cord.  Spencer's  cut  illustrates  the 
relation  of  the  structures  in  an  admirable  manner  (Fig.  1453). 

The  Palliative  Treatment.— The  pallia- 
tive treatment  consists  in  raising  the  scro- 
tum and  its  contents,  thus  lessening  the  trac- 
tion on  the  cord  of  the  column  of  blood 
contained  in  the  vessels.  This  plan  of  treat- 
ment is  effected  by  the  various  forms  of  sus- 
pensories, as  Morgan's  (Fig.  1454),  and  the 
one  in  common  use.  If  these  measures  re- 
lieve the  urgent  symptoms,  an  operation  may 
not  be  desired.  If,  however,  the  character- 
istic symptoms  recur  or  continue,  then,  if 
preferred,  the  palliative  operation  of  shorten- 
ing the  scrotum  by  excision  can  be  performed. 

The  Excision  of  the  Scrotum.— The  abridgment  of  the  scrotum  by  exci- 
sion of  the  lower  portion  and  repair  of  the  wound  raises  up  its  contents  and 


Fig.  1454. — Morgan's  suspensory. 


1228 


OPERATIVE  SURGERY. 


thereby  relieves  the  tension  on  the  cord,  the  same  as  by  the  use  of  a  sus- 
pensory. 

Tlie  Operation. — Thoroughly  cleanse  the  scrotum  and  anaesthetize  the 
patient;  apply  theclam})  (Fig.  1455)  with  the  bar  {a)  adjusted  to  the  affected 
side,  nearly  parallel  with  the  median  rhaphe,  by  drawing  between  the  blades 
a  sufficient  amount  of  scrotal  tissue  ;  press  the  testicle  upward  to  the  external 
ring  to  avoid  its  inclusion  by  the  clamp  ;  tighten  the  blades  of  the  instrument 
amply  to  control  the  circulation  and  securely  hold  the  scrotal  tissue  ;  transfix 
the  protruding  portion  of  the  scrotum  on  a  level  with  the  adjustable  bar 

(Fig.  1455)  with  a  sharp,  narrow-bladed  bis- 
toury and  cut  it  off ;  pass  the  sutures  through 
the  divided  borders  (beneath  the  bar)  before 
the  blades  of  the  clamp  are  loosened ;  loosen 
the  clamp  and  catch  and  tie  the  bleeding 
points  with  catgut  before  tying  the  sutures. 
Tie  the  sutures,  place  the  patient  in  bed,  ele- 
vate the  scrotum,  and  dress  the  part  with 
gauze.  The  wound  usually  heals  quickly,  and 
the  result  affords  a  relief  that  amply  recom- 
penses the  patient  for  the  annoyance  incurred. 
If  the  clamp  just  described  be  not  at  hand, 
the  operation  should  not  be  rejected  for  this 
reason,  as  a  clamp  of  practical  utility  may  be 
extemporized  from  long-handled  forceps,  or 
by  adjusting  to  the  scrotum  two  narrow  bars 
of  metal  or  stiff  wood,  the  extremities  of 
which  can  be  firmly  held  by  elastic  bands  or 
by  the  hands  of  an  assistant. 

The  Precautions. — Care  should  be  taken 
to  arrest  all  bleeding  points  before  the  bor- 
ders of  the  wound  are  united,  to  avoid  the  ex- 
tensive extravasation  of  blood  that  the  loose 
tissue  of  the  scrotum  invites.  In  case  extrava- 
sation happens,  the  blood  should  be  removed 
at  once  from  the  tissues  and  the  bleeding 
point  found  and  tied. 

The  Radical  Treatment  of  Varicocele. — The 
Fig.  14o5.-Henrys  scrotal  clamp.  ^^^^^^  employed  to  obliterate  the  dilated  ves- 
sels are  quite  numerous.  They  all,  however,  accomplish  the  result  by  com- 
pression. Only  such  as  are  considered  consistent  with  the  safety  of  the 
patient  are  here  described.  It  will  be  noted  that  in  some  instances  the 
operation  is  an  open  one — the  vessels  being  reached  through  one  or  more 
free  incisions.     In  others,  puncturing  only  is  practiced  for  this  purpose. 

In  each  of  the  operations  great  care  must  be  exercised  to  avoid  the  vas 
deferens  and  artery.  Therefore  it  is  proper  to  repeat  the  fact  that  they  lie 
posteriorly  to  the  enlarged  and  wormlike  congeries  of  vessels  (page  1453), 
around  which  the  compression  is  usually  applied.     If  the  patient  be  caused 


OPKRATIOXS   OX   THE   SCKOTL'M    AND    I'KNIS. 


1220 


to  lie  down  with  the  liips  eloviitcil,  the  bhjod  will  ivturii  from  the  varieose 
veins  into  the  general  eircuhition,  after  which  the  vas  deferens  and  the  artery 
can  be  easily  isolated  and  separated  from  the  veins.  If  the  patient  then 
assumes  an  erect  position,  the  veins  will  again  becotne  distended  ;  after 
which,  if  pressure  be  maintained  npon  the  cord  at  the  external  ring  by  any 
effective  agency,  the  vessels  can  be  distinctly  outlined  with  the  patient  placed 
again  in  the  recumbent  position.  The  operator  having  thus  carefully  iso- 
lated the  vas  deferens  and  the  artery,  the  patient  can  be  etherized  and  the 
operation  performed. 

The  Compression  witli  Pins  (Fig.  145G). — Compression  with  pins  con- 
sists simply  in  passing  a  strong  pin  through  the  scrotal  tissues  in  front  of 
the  vas  deferens  and  the  artery  and  behind  the  varicose  veins,  and  throwing 
around  its  protruding  extremities,  so  as  to  include  the  tissue  in  front,  an 
elastic  ligature,  or  cotton  yarn,  drawn  sufficiently  tight  to  cut  off  the  circu- 
lation.    This  procedure  should  be  repeated  at  a  distance  of  about  one  inch 


Fig.  1456.— Occlusion      Fig.  1457.— Wires  m      Fig.  1458.  — Wires      Fig.  14-59. —Vessels 
by  pins.  position.      Videl's  twisted.    VideFs  occhided.    Videl's 

operation.  operation.  operation. 

from  the  site  of  the  first  application.  The  pins  can  be  withdrawn  at  the  end 
of  three  or  four  days. 

The  Compression  loith  Wires  (Videl). — The  treatment  by  compression 
with  wires  is  made  by  passing  a  stout  wire  either  in  front  of  or  behind  the 
veins — preferably  the  latter — then  passing  a  second  but  smaller  one  at  the 
opposite  side,  but  through  the  same  opening  in  the  integument  (Fig.  1457). 
The  wires  are  then  twisted  together  till  the  veins  are  thoroughly  compressed 
and  rolled  around  them  (Figs.  1458  and  1459). 

Erichsen  modified  this  method  somewhat  by  making  an  incision  half  an 
inch  in  length  at  the  front  and  at  the  back  of  the  scrotum,  through  which  a 
needle  armed  with  a  small  silver  wire  is  carried  backward  in  front  of  the 
vas  deferens  and  the  artery,  thence  forward  beneath  the  integument  around 
the  enlarged  veins,  and  the  ends  of  the  wire  twisted  together  so  as  to  con- 
strict firmly  the  included  vessels.  Daily  tightening  of  the  grasp  of  the  wire 
is  practiced  for  a  week  or  ten  days,  or  until  the  vessels  are  severed  by  the 
process  of  ulceration. 


1230 


OPERATIVE   SUKGERY. 


Subcutaneous  Ligaturing. — .Strong  catgut  ligatures  or  antiseptic  sillc  can 
be  curried  around  tiie  dilated  veins,  at  points  an  inch  or  so  apart,  by  means 
of  an  ordinary  needle — or  by  an  instrument  especially  devised  for  the  pur- 
pose— and  caused  to  emerge  at  the  points  of  entrance,  tied,  ends  cut  short, 
and  ligatures  permitted  to  remain  until  they  are  absorbed. 

Reyes's  Method. — A  needle  with  a  fixed  handle,  having  two  eyes  at  the 
point,  one  behind  the  other  (Fig.  14G0),  is  armed  with  two  antiseptic  liga- 
tures, one  carried  through  each  eye.     The  ends  of  the  i^osterior  ligature  are 


Fiii.   1460. — Keves's  double-eved  needle. 


tied  to  form  a  loop ;  the  anterior  ligature  is  permitted  to  hang  loosely,  with 
an  equal  portion  at  each  side  of  the  needle.  The  enlarged  veins  are  isolated, 
and  the  point  of  the  needle  is  pushed  through  the  scrotal  tissues  at  one  or 
more  situations  in  close  contact  with  the  posterior  surface  of  these  vessels 
(Fig.  1461).  One  end  of  the  untied  ligature  is  then  drawn  through  the  tis- 
sues with  forceps,  and  caused  to  remain  in  this  position,  while  the  needle  is 
withdrawn  sufficiently  to  permit  its  point  to  be  carried  in  front  of  the  dis- 
tended veins,  and  out  again  through 
the  original  point  of  exit,  when  the 
distal  end  of  the  untied  ligature  is 
l^assed  through  the  advanced  portion 
of  the  looped  ligature,  and  drawn  by 
it  backward  and  out  through  the 
point  of  entrance  to  the  scrotal  tis- 
sues by  the  complete  withdrawal  of 
the  needle.  The  deposited  ligature 
is  then  freed  from  the  scrotal  tissues 
by  making  one  or  two  sharp  pulls 
upon  it,  tied  firmly  around  the  veins, 
its  extremities  cut  short  and  allowed 
to  disappear  within  the  scrotum.  If 
Fig.  1461.— Keves's  operation  for  varicocele,  thorough  antiseptic  i)recautions  be 
Passing  ligatures  with  single-eyed  needle  observed,  the  ligatures  will  rarely 
at  different  situations.  ,  .^^.        ^  ^ 

cause  subsequent  local  trouble. 

The  Double-loop  Comjnession  of  Ricord  (Fig.  1462). — This  plan  is  an  ex- 
cellent one  of  the  kind,  and  can  be  readily  executed  by  passing  a  needle 
armed  with  a  silk  ligature  between  the  veins  and 
the  vas  deferens  and  artery ;  to  this  is  fastened  a 
double  ligature,  which  is  drawn  through  and  left 
in  position.     The  needle  with  its  silk  ligature  is 
then  passed  in  front  of  the  veins  in  the  opposite 
direction,  entering  and  emerging  at  the  points 
previously  made.      A   second  double  ligature  is 
then  drawn  through  and  left  in  position.     The  extremities  on  the  respec- 
tive sides  are  now  tucked  through  the  loops  on  the  same  side,  and  drawn 


Fig.  14G2. — Rieonl's  loops. 


OI'KUA'IMONS   ()\    'I'llH   SCKo'rrM    AM)    I'KNIS. 


iL>;;i 


tiglit  aiul   tied   ovit  a    narrow  antiseptic  roller  or  ])ieee  of  elastic  tiiljing. 
The  ligatures  will  ciil  their  way  through  in  live  or  six  days. 

Free  Incision  with  Excision  (llowse). — In  this  operation  the  superlicial 
veins  are  exposed  by  direct  incision  and  careful  isolation,  and  a  segment  of 
an  incii  or  so  is  removed  independently,  between  two  catgut  ligatures,  fnjin 
each  of  them. 

The  ()jtcrati(i)i. — After  strict  antiseptic  preparation  in  all  respects,  cause 
an  assistant  to  grasp  and  gently  draw  downward  on  the  testicles  of  the  af- 
fected side  to  make  the  cord  tense ;  make  an  incision  an  inch  and  a  half  in 
length  over  the  most  promi- 
nent part  of  the  varicocele ; 
draw  the  borders  of  the  wound 
apart  and  carefully  expose  the 
veins  for  an  inch  and  a  half 
by  blunt  dissection,  avoiding 
severance  of  the  cremaster 
muscle  and  ex])08ure  of  the 
vas  deferens  and  its  vessels ; 
(Fig.  1463)  hook  up  the  ex- 
posed veins  and  pass  around 
them,  an  inch  and  a  half 
apart,  two  catgut  ligatures ; 
tie  the  lower  ligature  first,  and 
remove  with  scissors  the  in- 
cluded portion  of  each  vein, 
after  tying  the  second ;  wash 

the  cavity  of  the  wound  with  an  aseptic  fluid,  unite  the  borders  without 
draiiuige,  and  dress  the  part  antiseptically.  The  patient  is  kept  quiet  for 
two  weeks,  and  a  week  later  may  return  to  business,  wearing  a  suspensory 
for  a  month  or  so  thereafter. 

Bennett's  Modification  of  Howse's  Method. — The  modification  of  Bennett 
contemplates  the  permanent  shortening  of  the  cord  by  the  removal  of  the 
connective  tissue  and  muscles,  along  with  the  dilated  superficial  veins.  The 
amount  to  be  removed  should  correspond  to  the  abnormal  lengthening  of 
the  cord,  as  estimated  by  the  comparative  pendency  of  the  testicle. 

The  Operation. — Through  a  free  incision  expose  the  fascia  that  directly 
surrounds  the  varicocele ;  carry  around  the  varicocele  outside  of  this  fascia, 
at  an  estimated  distance  apart,  two  long,  strong  catgut  ligatures ;  tie  the  liga- 
tures firmly  around  the  included  tissue,  and  resect  it  at  about  a  quarter  of  an 
inch  from  the  points  of  constriction  ;  bring  the  ends  of  the  stumps  together, 
and  hold  them  there  by  tying  to  each  other  the  ends  of  the  respective  liga- 
tures, supplemented  by  a  catgut  stitch  or  two,  if  needed  ;  cut  the  catgut  ends 
short;  close  the  wound  without  drainage,  and  dress  it  as  before.  The  writer 
has  employed  this  method  in  several  instajices  with  entire  success. 

The  Precaiifions. — In  order  to  avoid  impairing  the  integrity  of  the  testi- 
cle, the  vas  deferens  and  the  artery  should  not  be  disturbed  in  any  of  the 
operations,  nor  should  the  veins  of  the  vas  be  treated  unless  decidedly  vari- 


FiG.  1463.- 


-The  operation  of  excision.  Howse's 
method. 


1232  OPERATIVE  SURGERY. 

cose,  which  is  infrequent.  There  is  danger  of  transfixion  of  a  vein  in  the 
passage  of  tlie  needle,  followed  by  extensive  ha^morrluige  into  and  sloughing 
of  the  scrotal  tissues.  The  writer  has  met  with  an  instance  of  this  kind  in 
his  own  experience.  Thorough  antiseptic  methods  should  be  i^racticed  in 
each  variety  of  procedure,  to  avoid  the  complications  of  infection.  If  the 
vessels  become  extensively  thrombosed,  confinement  in  bed  for  a  longer  time 
is  required. 

The  Remarks. — The  operation  of  free  incision  with  excision  is  attended 
with  no  uncertainty  in  technique.  But  the  obscurity  attending  the  utiliza- 
tion of  pins,  ligatures,  and  wire  is  objectionable  because  of  the  blindness 
of  the  procedure.  The  injection  of  a  few  drops  of  a  weak  solution  of  cocain 
at  the  seat  of  puncture  will  minimize  the  pain  of  application  of  pins  and 
ligatures.  The  tying  of  subcutaneous  ligatures  causes  momentarily  severe 
pain,  sometimes  attended  with  nausea  and  faintness.  If  the  patient  be 
caused  to  stand  in  a  warm  room,  the  veins  will  soon  become  distended. 
Pressure  on  the  cord  at  the  external  ring,  with  the  patient  in  the  recumbent 
posture,  is  followed  by  a  similar  result.  Only  the  superficial  veins — pam- 
piniform plexus,  as  a  rule — should  be  treated.  The  cremasteric  artery  is 
always,  and  the  spermatic  artery  is  often,  included  in  the  constriction  by  the 
indirect  method  (Figs.  1451  and  1452). 

The  Choice  of  Operation. — Subcutaneous  ligaturing  will  be  the  choice  of 
those  who  object  to  the  employment  of  anesthesia.  The  writer  has  prac- 
ticed Keyes's  method  frequently,  with  but  one  unfavorable  result,  which 
has  been  already  mentioned  above.  Latterly,  however,  the  excision  plan 
has  given  us  entire  satisfaction,  and  jjossesses  the  advantage  of  a  definite 
knowledge  of  the  tissues  involved.  The  difference  in  tlie  comparative  length 
of  the  periods  of  recovery  in  either  instance  is  not  sufficient  to  exercise  a 
controlling  influence  in  the  selection  of  the  plan  of  action.  Xotwithstand- 
iug  the  extremely  satisfactory  results  thus  far  obtained  by  us  in  the  excision 
methods,  we  are  not  blind  to  the  possibility  that  gangrene  may  happen  from 
impaired  circulation  in  the  part  below.  We  therefore  disturb  the  tissues 
during  dissection  as  little  as  possible,  and  leave  unimpaired  two  or  more  of 
the  smaller  veins  in  debilitated  subjects  and  those  with  unusually  pendulous 
tissues. 

The  Results. — Local  septic  complications  may  follow,  especially  in  the 
absence  of  requisite  antiseptic  technique.  With  proper  care,  the  danger 
to  life  from  the  operation  is  insignificant.  The  prognosis  for  cure  is  always 
good,  but  much  better  in  excision  than  in  the  other  methods. 

The  Repair  of  the  Vas  Deferens. — Division  of  the  vas  deferens  during 
operation  for  hernia,  or  injury  of  it  from  severe  contusion  of  the  cord,  may 
call  for  repair  of  the  damaged  structure.  The  technique  of  restoration  em- 
ployed in  the  surgery  of  the  ureter  is  of  equal  utility  in  the  repair  of  the  vas 
deferens  (page  85G).  However,  as  yet  but  little  has  been  done  in  this  direc- 
tion for  apparent  reasons. 

Elephantiasis  of  the  Scrotum  — Elephantiasis  of  this  structure  is  com- 
paratively rare,  occurring  more  often  in  the  colored  than  in  the  white  race. 
The  growth  is  commonly  a  disfigurement,  and  often  becomes  so  cumber- 


OI'KIJATIUNS  ON   TIIK   SCROTUM   AND    PENIS.  1233 

some  as  to  impede  lueomotiuii.  If  tlie  cause  exist  only  in  tlie  scrotal  lym- 
phatics the  removal  of  the  mass  will  elfect  a  cure,  otherwise  only  j)alliation 
will  be  etfected.  Shock  and  loss  of  blood  are  the  especial  dangers  of  opera- 
tion. However,  in  tlie  young  ami  in  fairly  vigorous  subjects  the  outcome 
is  excellent. 

The  Preparatory  Steps. — After  the  requisite  general  treatment  with 
stimulants,  etc.,  anil  local  antiseptic  measures,  i)lace  the  patient  on  the 
operating  table  on  the  back,  and  remove  him  to  the  place  of  operation,  espe- 
cially if  the  tumor  be  a  large  one ;  raise  the  growth  well  above  the  patient 
and  fasten  it  thus  to  i)ermit  the  outtlow  of  the  blood  and  lymph  and  the 
return  to  the  abdomen  of  a  com})licating  hernia;  asepticize  thoroughly  the 
field  of  operation  and  mark  out  the  lines  of  the  proposed  incisions — i.  e.,  if 
possible — where  the  healthy  and  diseased  tissues  meet. 

T/ie  Operation. — Anesthetize  and  bring  the  ])atient  to  the  edge  of  the 
table,  placing  him  in  the  lithotomy  position  ;  control  htemorrhage  by  passing 
firmly  around  the  root  of  the  tumor  (crossing  at  the  pubis)  to  the  opposite 
sides  of  the  body  the  ends  of  a  strong  rubber  tube,  tying  them  together 
securely  behind  the  back ;  cause  an  assistant  to  support  the  tumor  in  the 
manner  to  facilitate  the  operative  steps ;  pass  a  long  grooved  director 
through  the  preputial  fold  upward  as  far  as  possible  and  cause  the  end  to 
press  strongly  against  the  overlying  tissues ;  make  a  free  incision  down  upon 
the  end  of  the  instrument  and  push  the  end  through  it;  divide  from  above 
downward  along  the  director  the  overlying  tissues,  thus  exposing  the  glans 
penis;  seize  the  glans  with  the  fingers  and  free  the  organ  by  blunt  dissection 
from  contiguous  tissues  for  four  or  five  inches ;  wrap  the  penis  in  antiseptic 
gauze  and  draw  it  aside;  make  an  incision  at  each  side  from  over  the  spine 
of  the  pubis  downward  sufficiently  to  expose  the  cord  down  to  the  testicle; 
free  the  testicle  and  cord  from  their  connections  by  blunt  dissection,  wrap 
them  in  gauze  and  carry  upward  on  the  abdomen ;  divide  transversely  in 
front  the  tissues  intervening  between  the  incisions  at  either  side;  carry  (with 
a  long  knife)  an  incision  from  that  made  down  upon  the  right  cord,  down- 
ward between  the  scrotum  and  perina?um,  thence  upward  at  the  left  side, 
ending  at  the  incision  made  upon  the  left  cord ;  sever  with  free  strokes  the 
tumor  from  the  body,  Avhile  carefully  holding  the  constricting  tube  in  place  ; 
relax  the  tube,  seize  and  ligature  the  bleeding  points  as  they  appear,  cut 
away  the  indurated  portions,  and  remove  the  testicles  if  hopelessly  diseased  ; 
arrest  oozing  with  hot,  wet  compresses  ;  unite  the  borders  of  the  perineal 
wound,  if  conditions  will  permit,  wrapping  in  the  testicles  if  practicable; 
surround  the  penis  with  gauze  saturated  with  carbolated  oil,  and  dress  the 
remaining  raw  surfaces  in  the  usual  manner ;  provide  a  suitable  exit  for 
urine,  and  support  the  parts  along  with  the  superimposed  dressings  with  the 
common  T-bandage,  dressing  them  thereafter  as  granulating  surfaces  are 
treated  at  other  parts  of  the  body. 

Tlie  Precautions.— The  surface  of  the  entire  mass  should  be  thoroughly 
cleansed  and  wrapped  in  antiseptic  dressings  before  the  operation  is  begun. 
The  rubber  constriction  tubes  should  be  securely  fastened  in  place  by  strips 
of  bandage  carried  upward  and  fastened  before   the   incisions   are    made. 


]23tl:  OPERATIVE  SURGERY. 

Preparatious  for  saline  transfusion  should  be  at  hand  before  the  operation  is 
commenced.  The  presence  of  a  hernial  jirotrusiou  should  be  determined 
before  amputation  is  practiced.  Urinary  discharges  should  be  carefully 
excluded  from  the  wound  throughout  the  course  of  repair. 

Tlie  Remarks. — In  large  tumors  the  length  of  the  cord  is  often  consid- 
erable, rendering  the  location  of  the  testicle  somewhat  problematical.  If 
suflicient  amount  of  healthy  tissues  be  at  disposal,  the  2)euis  and  testicles 
should  be  properly  surrounded,  otherwise  stem  grafting  may  be  practiced 
then  or  at  a  later  date. 

Tlte  Results. — Only  about  five  per  cent  die  from  the  operation.  The 
parts  usually  heal  promptly,  the  penis  and  testicles  being  covered  with 
cicatricial  tissue  if  not  otherwise  better  provided.  Sometimes  the  disease 
returns,  usually  more  or  less  slowly,  the  patient  remaining  comparatively 
free  for  a  term  of  years.  If  the  testicles  are  unaffected  their  function  is  not 
necessarily  impaired  by  the  operation  and  its  sequels. 

COXGEXITAL    MALFOKMATIOX    OF    THE    URETHRA. 

The  urethra  may  be  absent  or  occluded ;  it  may  be  extremely  small  or 
bifid  ;  the  external  opening  may  be  higher  or  lower  than  normal,  and  even 
double;  its  walls  may  be  deficient  above  or  below,  constituting  epispadias 
and  hypospadias  respectively.  Epispadias  is  sometimes  complicated  by  sepa- 
ration of  the  symphysis  pubis  and  exstrophy  of  the  bladder.  In  many 
instances  these  deformities  are  a  great  affliction  during  life,  and  later  often 
become  especially  so  when  the  sexual  gravity  of  the  deformity  is  realized. 

The  operations  are  performed  easier  and  with  better  success  after  the 
period  of  infancy,  as  then  the  patient  is  the  better  controlled  and  the  organ 
of  a  larger  size.  Responsive  co-operation  is  best  secured  when  the  jiatient 
suffers  from  the  chagrin  incident  to  the  appreciation  of  the  importance  of 
the  deformity.  The  preparatory  measures  in  the  treatment  of  these  deformi- 
ties refer  more  especially  to  the  general  fitting  of  the  patient  for  the  pur- 
pose and  to  the  requirements  of  special  complications  demanding  independent 
action,  as  exstrophy  of  the  bladder.  The  preparatory  treatment  of  the  indi- 
vidual operations  will  appear  under  the  proper  titles. 

Hypospadias  results  from  a  deficiency  in  the  floor  of  the  urethra.  The 
opening  may  be  in  the  glans,  or  in  the  penile  or  scrotal  portions.  The  first 
form  is  the  most  frequent  and  the  least  important.  The  scrotal,  with  and 
without  perineal  involvement,  is  the  next  in  point  of  frequency,  and  the 
most  important  of  all.  They  may  be  designated,  therefore,  as  balanic, 
penile,  and  scrotal  hypospadias  respectively.  Mixed  varieties  of  this  deform- 
ity, such  as  glandulo-penile,  peno-scrotal,  and  perineo-scrotal  (page  1244), 
are  sometimes  seen. 

The  Preparation. — Before  the  operation  the  urine  should  be  drawn  and 
the  parts  thoroughly  cleansed.  Chloroform  anesthesia  is  advisable  if  no 
contra-indications  to  its  use  be  present.  The  penis  is  then  confined  to  the 
strip  of  wood  (Fig.  1464,^?)  by  means  of  the  pins  passed  through  the  cuta- 
neous borders  of  the  organ,  in  order  that  it  may  be  the  better  controlled 
during  the  manipulative  measures. 


Ul'KKATlUNS  UN    TUK  SC'K(/rLM    AND    I'KMS. 


1  'l'Vr> 


Fiu.  1464. — Instruments  employed  in  repair  of  urethral  defects. 

a.  Small  scalpels,  b.  Bistoury,  c.  Fine-pointed  forcipressure.  d.  j\Iouse-tooth  ami  dis- 
secting forceps,  e.  Needle-holder.  /.  Short  blunt-pointed  straight  and  curved  scis- 
sors, g.  h.  Single  and  double  tenacnla.  i.  Steel  sound,  j.  Flexible  catheter,  k. 
Long  silver  probe.  I.  Traction  loops,  m.  Small  straight  and  curved  needles,  n. 
Langenbeck's  clamps,  o.  Horsehair,  silkworm  gut,  and  catgut,  p.  Small  strip  of 
board  and  pins,  to  which  the  penis  is  confined  during  repair,     q.  Perforated  shot. 

Gouley's  Method  (Fig.  14G5). — Gouley's  method  is  especially  applicable 
to  the  balanic  variety. 

The  Operation. — Make  two  longitudinal  cuts  at  either  side  of  the  penis, 
flr,  b  and  a,  h,  far  enough  apart  to  leave  ample  material  for  the  new  urethi-a; 
make  cuts  r,  d  and  c,  d,  a.  b,  a  quarter  of  an  inch  outside  ;  remove  the  integu- 
ment of  the  spaces  bounded  by  these  incisions ;  leave  undisturbed  the  skin 
and  mucous  membrane  included  between  the  incisions  a,  b;  slide  the  loose 
skin  at  the  root  of  the  penis  and  of  the  scrotum  forward,  making  the  flap 
double  upon  itself,  until  b,  b  is  brought  forward  to  a,  a  and  the  denuded  sur- 
faces at  the  sides  of  the  penis  are  brought  in  accurate  apposition  with  the 
borders  of  the  reflected  flap,  making  the  angle  of  the  fold  at  e,  e.  The  first 
suture  is  taken  at  //,  and  passes  from  within  (beneath)  outward  through  the 
reflected  part  of  the  urethral  flap,  thence  from  without  inward  through  the 
84 


1236 


OPERATIVE   SURGERY. 


lower  and  imreflected  portion  to  near  the  point  of  starting,  thus  uniting 
together  near  to  the  point  of  folding  the  reflected  and  unreflected  por- 
tions of  the  urethral  flap.  Before  tying,  pass  the 
suture  of  the  opposite  side  in  the  same  manner ; 
tie  both,  cut  the  ends  short,  leaving  the  knots 
inside  the  new  urethra;  introduce  sutures  along 
the  external  borders,  uniting  them  closely  to- 
gether. The  newly  formed  meatus  is  transverse, 
its  under  lip  being  the  fold  of  the  skin  from  /, 
formed  by  the  apposition  of  the  points  b,  b  to  a,  a. 
If  curved  the  organ  should  first  be  straightened 
(page  1237). 

Anger's  Method  (Fig.  146G). — dinger's  method 
is  a  commendable  procedure  for  the  repair  of  de- 
formity at  the  penile  portion  only.  The  general 
and  special  preparatory  measures  of  the  preceding 
plan  are  of  equal  importance  in  this  one. 
*^^  The  Operation. — Make  an  incision  at  the  left 

Fig.  1465.— Gouley's  method,   side  of  the  penis,  from  the  glans  to  the  scrotum, 

a,  b,  half  an  inch  from  the  median  line ;  also  inci- 
sions at  a,  c  and  b,  d.  The  flap  thus  formed,  .r,  is  dissected  up,  its  base  being 
attached  near  to  the  median  line,  c,  d.  A  second  longitudinal  incision,  e,/, 
is  made  at  the  right  side  of  the  median  line,  near  to  it,  and  of  the  same 
length  as  a,  Z»,  with  lateral  incisions  an  inch  and  a  half  long  at  each  extrem- 
ity,/, ^  and  e,  h  (Fig.  1466).  The  flaps  are  raised,  a  sound  introduced  into 
the  urethral  groove, 
and  the  first  flap,  .r, 
turned  over  it,  bring- 
ing the  integument- 
ary portion  in  con- 
tact with  the  sound 
(Fig.  1467).  Inde- 
pendent sutures,  each 
armed  with  a  needle, 
are  passed  through 
the  free  margin  of 
the  first  flap,  x,  and 
outward  through  the 
base  of  the  second  Fig.  1466.— Anger's 
flap,  V,  and  fastened  operation  for  hy- 
^  ,     ,  1        pospadias,       first 

by       shot       pressed      g^ep. 

around  them  (Fig. 
1468).  The  remaining  flap,  y,  is  then  placed  upon  the  raw  surface  of  the 
first,  X,  and  fastened  to  the  margin  of  the  first  incision,  «,  b,  in  a  similar 
manner  or  by  sutures.     The  sound  or  catheter  is  then  removed. 

Duplay's  Method.— Duplay's  method  is  divided  into  three  steps.     1.  If 
the  penis  be  incurved,  it  is  straightened  and  a  new  meatus  made.     3.  The 


wm 


Fig.  1467.— Anger's 
operation  for  hy- 
pospadias, second 
step. 


Fig.  1468.— Anger's 
operation  for  hy- 
pospadias, third 
step. 


Ol'KUA'l'IONS   OX   TlIK   SCIfOTLIM    AND    I'KXIS. 


1237 


missing  portion  of  llic  uivtlmi  is  rcstorecl.     .'5.  The  old  and  new  jiarts  are 
joined  together. 

The  poiis  is  straigltteupd  by  making  transverse  subcutaneous  incisions 
througli  tlie  restraining  bands  wliile  the  organ  is  being  extended;  if  the  in- 
tegument be  too  taut  to  admit  of  the  proper  rectification,  it,  too,  must  be 
severed.  Tlie  resulting  cuts  are  united  in  the  long  axis  of  the  penis,  and  the 
l)enis  confined  in  the  corrected  position  a  suffi- 
cient time  to  permit  the  healing  of  the  wound 
before  the  second  step  of  the  ojieration  is  at- 
tempted. It  may  be  necessary  to  rei)eat  this  cor- 
rective measure  two  or  tliree  times  before  the 
proper  position  of  the  organ  is  gained.  At  all 
events,  eight  or  ten  months  will  no  doubt  elapse 
before  the  organ  is  properly  suited  for  the  final 
step  (page  1:241). 

The  first  step  is  completed  by  freshening,  and, 
if  necessary,  deepening  the  urethral  groove  at  the 
situation  of  the  pro2)osed  meatus,  and  uniting  its 
raw  surfaces  with  silkworm  gut  or  carbolized  silk 
around  a  sound  or  gum  catheter,  as  in  Thiersch's 
method  (page  1241). 

The  Second  Step. — Pin  the  penis  to  the  strip 
of  wood  (Fig.  1464,  jo)  and  make  two  longitudi- 
nal incisions,  a,  «',  extending  from  the  glans  to 
near  the  abnormal  opening  (2),  one  on  each  side 
of  the  urethral  groove,  at  a  distance  from  each 
other  equal  to  little  more  than  half  the  circumfer- 
ence of  the  proposed  urethra,  a  dimension  which 

can  be  ascertained  by  measuring  the  gum  catheter  over  which  the  flaps  are  to 
be  reflected.  From  the  ends  of  each  of  these  a  transverse  incision  is  made 
toward,  but  not  quite  to,  the  median  line.  The  flaps,  x  and  y,  are  dissected 
up  and  turned  inward  over  a  gum  catheter,  c  (Fig.  1470),  and  their  margins 


Fui.  1469.— Duplay's  inclhod 
for  hypospadias.  Forniing 
flaps. 


Fig.  1470. 


-Duplav's  incthod.  transverse  section.     1.  Showing  relation  of  flaps.    2.  Flaps 
reflected.     3.  Flaps  nearly  apposed. 


fastened  together  in  the  median  line  by  fine  catgut  sutures  (.?•,  ij).    The  outer 
flaps,  a  and  h,  of  the  longitudinal  incision  are  dissected  up  at  the  ends  and 


1238 


OPERATIVE  SURGERY. 


sides  sufficiently  to  permit  them  to  be  easily  drawn  over  the  reflected  flaps,  x 
and  ?/,  when  they,  too,  are  united  in  the  median  line  by  interrupted  or  con- 
tinuous sutures.  The  quilled  suture  (Fig.  140),  with  shot  fastening,  is  ad- 
missible for  the  purpose.  Unite  the  anterior  extremities  of  all  the  flaps  to  the 
raw  borders  of  the  glans,  thus  completing  the  anterior  portion  of  the  tube. 

Tlie  Third  Step. — The  third  step  is  delayed  for  three  or  four  months,  or 
at  least  until  the  suitable  repair  of  the  preceding  ones  is  established.  Then 
the  edges  of  the  abnormal  opening  at  the  base  of  the  penis  {z)  are  freshened 
and  united  over  a  catheter  by  means  of  deep  quilled  and  superficial  inter- 
rupted catgut  sutures.  In  the  absence  of  indications  to  the  contrary,  the 
catheter  may  be  permitted  to  remain  during  recovery. 

Szymanowski's  Method  (Fig.  1471).— Szymanowski's  method  is  an  ingen- 
ious and  efficient  plan  of  closure  of  large  congenital  and  acquired  urethral 
defects. 

The  Oinration. — Make  an  incision,  «,  «,  near  the  edge  of  the  fistula,  ex- 
tending half  an  inch  beyond  it  at  either  end ;  dissect  up  from  within  outward 
a  flap  \x)  bounded  by  the  dotted  line ;  make  a  curved  incision,  I,  h,  at  the 


Fig.  1471. — Szymanowski's  method  of  closure  of  large  defects  in  urethra. 

opposite  side,  its  length  being  a  trifle  less  than  that  marked  by  the  dotted 
line  of  the  opposite  side,  but  otherwise  of  sufficient  width  to  cover  the  fistula 
and  reach  the  dotted  line  when  turned  upon  itself ;  scrape  the  cuticle  from 
the  flap, ;?/,  and  dissect  it  up  to  the  edge  of  the  fistula;  arm  each  end  of  a  fine 
carbolized  silk  suture  with  a  small  curved  needle ;  pass  these  two  needles  from 
the  epidermic  surface,  about  a  quarter  to  a  sixth  of  an  inch  apart,  through 
the  edge  of  the  curled  flap  (Fig.  1471,  2),  introducing  them  from  within  out- 
ward— corresponding  to  the  dotted  line — through  the  base  of  the  flap  {x) 
formed  by  the  straight  incision  ;  after  passing  a  sufficient  number  of  these 
sutures — one  every  quarter  inch — draw  the  curved  flap  beneath  the  straight 
one  into  the  space  formed  by  the  separation  of  the  latter,  so  that  its  edge 
will  correspond  to  the  dotted  curved  line  (Fig.  1471,  3),  and  secure  the  sutures 


OI'KKATIOXS   ON    TlIK   SCKUTLM    AND    I'HNIS.  \2:>/J 

over  a  piece  of  (|uill  or  cork,  or  fasten  them  with  shot.  The  inner  edge  of 
the  straight  fhip  is  now  united  to  the  outer  edge  of  tlie  curved  one,  and  the 
operation  is  completed. 

T/ie  Remarks. — The  use  of  the  scrotal  and  preputial  tissues  for  primary 
reparative  ilaps  is  not  advisable,  unless  Haps  from  other  sources  are  out  of 
the  question.  The  peculiar  structure  of  these  tissues  interposes  an  obstacle 
to  prompt  healing  by  reason  of  oodematous  swelling  and  corrugation.  How- 
ever, when  necessary,  these  tissues  can  be  employed  with  satisfaction  to  close 
small  openings  directly,  or  to  supplement  the  use  of  the  more  reliable  struc- 
tures. It  is  wise  to  correct  the  penile  deformity  as  early  as  possible,  in  order 
to  stimulate  its  growth  to  the  fullest  extent.  The  buried  sutures  should  be 
of  catgut,  the  others  of  silkworm  gut  or  horsehair.  The  raw  surfaces  should 
be  accurately  apposed,  and  the  sutures  not  tightly  drawn.  If  the  line  of 
apposition  be  puckered  iu  places,  primary  union  there  will  fail  to  take  place, 
and  extravasation  of  urine  may  occur  and  small  troublesome  fistiiliB  follow. 
Usually,  however,  these  fistulous  openings  heal  quite  readily  at  a  later  period 
with  instrumental  dilatation  of  the  urethra.  After  union  of  the  borders  of 
the  wound,  the  organ  is  dressed  lightly  with  iodoform  gauze  and  carefully 
supported  in  the  most  comfortable  position.  The  application  to  the  borders 
of  a  narrow  dressing  of  iodoformized  collodion  protects  them  from  external 
infection  and  holds  them  steadily  in  place.  But  if  this  dressiiig  contract 
overmuch,  the  urinary  channel  may  be  narrowed  and  the  escape  of  urine 
correspondingly  impeded,  especially  if  much  swelling  takes  place.  The  re- 
tention in  the  bladder  of  a  rubber  catheter  for  two  or  three  days  is  some- 
times practiced  with  satisfactory  outcome.  However,  the  irritation  of  the 
instrument  and  the  escape  of  urine  along  the  side  may  produce  much  trouble, 
and  require  a  prompt  withdrawal.  The  charging  of  the  urethra  with  steril- 
ized oil  at  the  time  of  introduction,  will  do  much  to  lessen  and  perhaps  may 
obviate  these  dangers  entirely.  The  writer  has  practiced  the  injection  of  a 
small  amount  of  sterilized  oil  into  the  urethra  before  each  alternate  act  of  mic- 
turition, for  two  or  three  days,  with  excellent  results.  The  repeated  introduc- 
tion of  the  catheter  at  this  time  is  objectionable,  especially  if  much  swelling 
be  present,  not  only  because  the  advancing  end  imperils  the  line  of  union, 
but  the  opposition  of  the  patient  may  cause  tearing  asunder  of  the  wound. 

The  Results.— The  dangers  to  life  with  proper  care  are  insignificant, 
indeed.  The  usefulness  of  the  organ  is  much  enhanced  if  the  operation  is 
done  as  early  in  life  as  possible.  The  general  results  in  older  subjects  are 
more  disappointing  in  the  final  outcome  than  are  those  of  the  younger.  Xot 
infrequently  a  small  and  even  persistent  fistula  may  follow  a  failure  of  union 
at  some  point,  but  the  repeated  use  of  sounds  will  frequently  assist  and  also 
add  to  the  completeness  of  the  cure  by  increasing  the  capacity  and  estab- 
lishing a  uniformity  of  the  diameter  of  the  urethral  canal. 

Epispadias. — Epispadias  results  from  a  deficiency  in  the  roof  of  the 
urethra.  This  deformity  is  less  frequent,  but  more  troublesome  and  diffi- 
cult to  cure  than  hypospadias.  In  this  also  the  penis  is  dwarfed  and  curved. 
In  some  instances  the  opening  into  the  bladder  is  exceedingly  large  and 
incontinence  of  urine  is  present.     However,  urinary  control  often  results 


12i0 


OPERATIVP]   SURGERY. 


Fig.  1472. — Xelaton's  method 
of  operation  for  epispadias. 
Formation  of  abdominal  (2) 
and  penile  flaps  (.r,  y). 


from  operation,  even  when  in  other  respects  it  can  not  be  regarded  as  suc- 
cessful.    The  ability  to  secure  as  satisfactory  results  in  this  as  in  the  pre- 
ceding deformitv  has  not  vet  been  attained. 

The  general  and  special  jji-efaration  of  the 
patient  and  the  parts,  and  the  attention  to  details 
during  and  after  operation,  are  substantially  those 
employed  in  hypospadias. 

Mlaton's  Method  (Fig.  1472). — Draw  the  pre- 
puce down  over  the  end  of  the  penis  and  hold  it 
there  with  a  ligature  during  operation;  adjust 
the  penis  to  the  strip  of  wood  (Fig.  1464,  jt?,) ; 
pin  it  in  place  and  make  a  longitudinal  incision 
along  each  side  of  the  urethral  gutter,  a,  a\  at  the 
junction  of  the  skin  and  mucous  membrane,  from 
tlie  corona  glandis  to  the  abdominal  wall ;  make 
a  right-angled  transverse  short  outward  incision 
from  the  ends  of  each  of  the  longitudinal  ones,  two 
or  three  lines  in  length  ;  dissect  outward  from  the 
exterior  lip  of  each  incision, «, «',  to  the  outer  limits 
of  the  transverse  incisions,  forming  two  flaps,  x 
and  y ;  mark  out  a  third  flap  on  the  abdominal 
wall,  2,  by  carrying  upward  from  the  outer  limits  of  the  proximal  transverse 
incision  two  parallel  incisions,  c,  e',  connecting  them  above  by  a  transverse 
cut ;  reflect  the  abdominal  flap,  z,  downward  so  as  to  form  the  roof  of  the  new 
urethra,  tlie  cutaneous  surface  being  undermost;  unite  over  a  catheter  the 
parallel  borders  of  the  abdominal  flap,  2,  to  the  inner  borders  of  the  primary 
incisions,  c<,  «',  a,  a'  (Fig.  1472) ;  re-enforce  the  abdominal  flap,  z^  by  a  scrotal 
one  (Fig.  1473,/')  limited  above  by  a  curved 
incision  circumscribing  the  under  half  of  I 

the  organ  at  the  peno-scrotal  junction  be- 
low by  an  incision,/,  parallel  with  the  flrst, 
located  the  length  of  the  penis  beneath 
the  upper  one,  and  each  extremity  remain-    \ 
ing  continuous  with  the  integument  of      \ 
the  outer  surface,  e ;  dissect  the  flap  up,         ^,     . 

slip  the  penis  under  it,  and  bring  the  raw    0 .-%-- 

surfaces  of  the  flaps  ( /  and  z)  in  contact  f 

with  each  other ;  unite  the  borders  of  the 
scrotal  flap  to  those  of  the  penile  flaps, 
X  and  y,  at  ^,  ^,  and  close  the  abdominal 
and  scrotal  wounds  with  sutures. 

The  Bemarks. — The  hair  bulbs  of  the 
jiroposed  abdominal  flap  should  be  de- 
stroyed, and  the  part  allowed  to  heal  be- 
fore the  flap  is  made,  to  avoid  the  subse- 
quent annoyance  of  the  capillary  growth, 
should  exceed  somewhat  the  distaiice  between  the  penile  parallel  incisions, 


Fig.  1473. — Xelaton's  method  of  opera- 
tion for  epispadias.  Formation  and 
ai)plication  of  scrotal  flap  (/). 

The  width  of  the  abdominal  flap 


()i'i;iv'A'ri()\s  ON  'rill';  scko'it.m  and  I'KMs. 


1241 


a,  (I,  in  ordor  to  ('st;il)lisli  ;i  capacious  urethra.  l''iiie  sutures  of  .siliv  or  of 
chromicized  catgut  iiuiy  be  oiiijdoycd.  If  urine  escapes  by  the  side  of  the 
cathotor,  or  the  instrninont  causes  irritation,  it  slioidd  be  removed  at  once, 
and  the  case  treated  as  in  hy()ospadias. 

The  After-treatment. — An  aseptic  and  well-oiled  catheter  is  introduced 
and  fastened  in  the  urethra;  the  parts  are  dusted  with  iodoform,  and  a  liglit 
gauze  dressing  is  apjilied  from  time  to  time  as  needed.  The  bladder  .should 
be  drained  through  the  catheter,  if  po.ssible,  in  the  manner  already  described 
(page  1114),  and  the  patient  and  the  bedding  kept  dry.  If  need  be,  the  sutures 
are  removed  in  a  week  or  ten  days  and  the  catheter  at  the  end  of  a  week. 

The  Iicsidts. — Witli  asejitic  attention  there  is  no  danger  to  life,  jjrompt 
and  satisfactory  healing  usually  takes  i>lace,  and  thereby  the  local  and  gen- 
eral conditions  are  much  improved. 

Thiersch's  Method. — In  Thiersch's  method  a  urethra  is  constructed  of 
more  nearly  the  normal  diameter,  and  the  glans  penis  is  covered.  This 
procedure  is  divided  into  four  stages,  and  requires  often  several  months  for 
its  completion. 

77ie  First  Stage  (Figs.  1474,  1475,  and  147G). — The  first  stage  relates  to 
the  construction  of  the  meatus  and  the  glandular  portion  of  the  urethra,  and 


Fig.  1474— Thiersch's  ineth- 
od  of  operation  for  epispa- 
dias, first  stage,  trans- 
verse section,  a,  a.  Con- 
verging incisions,  c.  Me- 
dian portion. 


Fig.  1475.— Thiersch's  meth- 
od of  operation  for  epispa- 
dias, first  stage.  Freshen- 
ing surface  of  glans. 


Fig.  1476. — Thiersch's  meth- 
od of  operation  for  epispa- 
dias, first  stage.  Depres- 
sion of  middle  portion  and 
union  with  pin. 


is  practiced  as  follows :  Make  a  deep  converging  incision  into  the  glans, 
three  fourths  of  its  thickness,  along  each  side  of  the  urethral  gutter  (a,  a, 
Fig.  1474) ;  freshen  a  narrow  surface  of  the  outer  portion  of  the  glaiis  the 
entire  length  of  the  incisions  (Fig.  1475) ;  depress  the  middle  portion  with  a 
catheter,  and  unite  together  around  it  the  lateral  portions  at  their  freshened 
surfaces,  holding  them  in  place  with  fine  needles  armed  with  iigure-of-eight 
sutures  (Fig.  1470),  or  with  silkworm-gut  sutures. 

The  Second  Stage. — In  the  second  stage  the  urethra  is  constructed. 
This  stage  is  not  begun  until  the  objects  of  the  preceding  one  are  com- 
pletely attained.  Then  make  an  incision  through  the  skin  and  subcuta- 
neous tissue  at  the  edge  of  the  urethral  gutter  at  the  right  side  (a,  a,  Fig. 
1477);  also  a  short  outward  transverse  cut  from  each  end,  a,  b.  ]Make  a 
second  incision  on  the  left  side,  parallel  with  the  preceding  one,  half  an 
incli  external  to  the  edge  of  the  urethral  gutter,  e,  c,  and  a  transverse  one 
at  each  extremity,  c,  d,  extending  inward  to  the  border  of  the  urethral 
groove.      Dissect  up  flaps  .r  and  ?/  (Fig.  1478),  making  them  as  thick  as 


1242 


OPERATIVE   SURGERY. 


practicable  ;  raise  and  turn  the  llap  y  over  a  catheter  in  tlie  urethral  gutter 
so  as  to  form  the  roof  of  the  new  channel,  its  raw  surface  being  uppermost 


Fig.  1478.— Thiersch's 
method  of  operation 
for  epispadias,  be- 
ginning of  second 
stage.  Transverse 
section,  showing 
formation  of  flaps 
X  and  y. 


Fig.  1477.— Thiersch's  meth- 
od of  operation  for  epispa- 
dias, beginning  of  second 
stage,  a,  a.  Proximal  in- 
cision, a,  b,  a,  b.  Short 
transverse  incisions,  c,  c. 
Distal  incision,  c,  d,  c,  d. 
Short  transverse  incisions. 
X  and  y.  Dorsal  flaps,  z. 
Fistulous  opening. 


Fig.  1479.— Thierscli's 
metliod  of  operation 
for  epispadias,  end- 
ing of  second  stage. 
Transverse  section, 
flaps  reflected. 


Fig.  1480.— Thiersch's  method 
of  operation  for  epispadias, 
completion  of  second  stage. 
(t.  Anterior  defect,  b.  Pre- 
puce. X.  Dorsal  flap,  z. 
Fistulous  opening. 


(Fig.  1479).     Pass  several  sutures  through  it  near  to  its  free  margin,  thence 
through  the  inner  border  of  the  first  incision,  «,  a  (Fig.  1477),  and  fasten 
z  them  by  a  quill  or  shot  attachment.     The  flap  x  is 

then  drawn  across  the  former,  so  that  their  raw 
surfaces  are  in  contact  throughout,  and  its  free 
margin,  o,  a,  joined  to  the  outer  side  of  the  incision, 
c,  c,  by  sutures  (Fig.  1480). 

Tlte  Third  Stage. — The  third  stage  consists 
(Fig.  1481)  in  closing  the  small  opening  located 
between  the  glans  penis  and  the  roof  of  the  ure- 
thra (Fig.  1480,  a).  The  prepuce  is  employed  for 
this  object  in  the  following  manner :  Raise  up  and 
buttonhole  the  pendulous  prepuce  {h)  at  the  lowest 
part,  and  press  the  glans  penis  through  the  open- 
ing; freshen  the  margins  of  the  gap  on  the  dorsum. 
Fig.  1481.— Thiersch's  meth-  and  close  it  with  a  flap  formed  from  the  reflected 
od  of  operation  for  epispa-    prepuce  close  at  hand  (Fig.  1481). 

dias,  third   stage.       Ante-  rrn      n        n    en  n^^      i?        iu     i  -J-        i.   J 

rior  defect  closed.  ^"^  Fourth  Stage. — The  fourth  stage  is  directed 

to  closing  the  opening  into  the  bladder  (Fig.  1480, 

z),  which  is  done  by  means  of  two  flaps — right  and  left  (Fig.  1482,  «,  b). 

The  left  (&)  is  taken  from  the  left  groin,  is  triangular  in  shape,  with  the 


OPKKATIO.NS   UN    Till':   SCltUTLM    AM>    I'KNIS. 


1243 


base  located  at  the  left  upper  half  of  the  opening,  and,  when  turned  down- 
wanl  with  the  raw  surface  uppermost,  forms  tlic  roof  of  the  opening  ( l"'ig. 
1482).     Its  margins  are  sewed  to  tlie  freshened  upper  border  of  the  new  roof 

\ 


Fig.  1482. — Thiersch's  metliod  of  operation 
for  epispadias,  fourth  stage.  Closure  of 
fistulous  opening. 


Fig.  148B. — Tliiersch's  method  of  operation 
for  epispadias.  Completion  of  fourth 
stage. 


of  the  urethra  (Fig.  1483).  The  right  flap  (a)  is  longer,  and  the  base  is 
located  at  the  right  external  abdominal  ring.  Its  raw  surface  is  placed  in 
contact  with  that  of  its  fellow,  aud  fastened  in  place  with  sutures  (Fig. 
1483)    addressed    to     the    contiguous     borders.  ^ 

The  remaining  raw  surface  (c)  is  permitted  to 
heal  by  granulation,  or  repaired  by  skin  graft- 
ing. 

The  Iiouarks. — A  proper  interval  should 
elapse  between  each  stage  of  the  operation,  to 
allow  of  complete  repair  of  the  preceding  steps 
and  a  suitable  estimate  of  their  success.  For 
merly  Thiersch  established  a  temporary  perineal 
fistula,  but  he  has  since  decided  tliat  with  proper 
care  it  need  not  be  made. 

Duplay's  Method. — In  Du play's,  as  in  the  pre- 
ceding method,  the  operation  is  divided  into  four 
stages : 

The  fir  fit  stage  is  allotted  to  the  straightening 
of  the  penis,  which  is  done  in  the  manner  already 
described  (page  l'-23T). 

The  Second  Stage. — In  the  second  stage  the 
urethra  is  formed  and  entirely  (Fig.  1484)  from 
the  central,  :r,  ./•,  penile  structures. 

A  strip  of  tissue  about  a  quarter  of  an  inch  in  width  is  freshened  at  each 
side  of  the  urethral  gutter  («,  a'),  and  the  freshened  surfaces  are  united  with 


Fig.  1484. — I)uplay"s  method 
of  operation  for  epispadias, 
second  stage,  a,  a'.  Fresh- 
ened surfaces,  z.  Fistulous 
opening. 


1244  OPERATIVE  SURGERY. 

each  other  over  a  catheter  by  means  of  quilled  sutures  (Fig.  1-485).  How- 
ever, if  the  urethral  groove  be  shallow  at  the  outset,  a  median  incision  (a) 
is  made  along  its  whole  length  to  facilitate  easier  adjust- 
ment of  the  freshened  surfaces. 

lite  Third  Stage. — In  the  third  stage  the  prepuce 
is  treated  as  in  Thiersch's  method,  and  so  arranged  on 
the  dorsum  of  the  organ  as  to  provide  a  sound  cutaneous 
covering  for  as  much  of  its  distal  part  as  is  possible. 

The  Fourth  Stage. — The  fourth  stage  is  devoted  to 

Pig.  1485.— Duplay's   the  closure  of  the  opening  into  the  bladder.     The  sur- 

method  of   opera-  f^ces  of  the  apposed  borders  of  the  gap  are  freshened 

of  epispadias,  com-   and  united  and  held  in  place  by  shotted  sutures. 

pletion  of    second  y/^g  Remarks. — The  same  aseptic  care  is  exercised  in 

incfsi'on."'  '       '      ^^^^^  as  in  the  preceding  methods.       If  permissible,  the 

catheter  is  allowed  to  remain  in  the  canal  with  the  end 

in  the  bladder  until  the  wound  is  safely  healed.     The  writer  has  practiced 

Thiersch's  method  repeatedly,  and  in  each  instance  with  entire  success.     In 

no  case  was  a  temporary  perineal  fistula  made. 

Perineal  Hypospadias  {^jerineo- scrotal). — This  form  of  hypospadias  is  the 
rarest  of  all  of  these  defects,  and  the  deformity  is  great  and  the  prospects  of 
success  of  operative  effort  more  uncertain  and  protracted  than  in  either 
of  the  preceding  instances.  The  conditions  of  the  penis  are  variable,  and 
often  complicating,  the  organ  sometimes  being  unusually  atrophied,  strongly 
incurved,  and  affixed  to  the  scrotal  fissure,  thus  obscuring  the  urinary  open- 
ing. 7V/e  operative  treatment  relates  to  remedying  the  penile  portion  of  the 
deformity  by  the  stated  method  suited  to  the  purpose,  followed  with  closure 
of  the  perineal  defect  by  direct  union  or  by  proper  flap  procedures. 

ACQUIKED    URETHRAL    DEFECTS. 

The  walls  of  the  urethra  may  suffer  loss  of  substance,  producing  a  fistula. 
The  caliber  of  the  canal  may  be  diminished,  causing  stricture,  either  of 
which  usually  depends  upon  acquired  causes. 

Before  attempting  an  operation  for  the  closure  of  a  urethral  fistula  the 
caliber  of  the  canal  should  be  made  as  near  to  its  normal  size  as  possible  by 
appropriate  treatment  of  the  strictures  and  such  other  obstructions  as  may 
exist  in  its  course. 

Urethrorrhaphy. — Urethrorrhaphy  is  employed  to  close  a  small  urethral 
fistula  not  exceeding  a  fifth  of  an  inch  in  diameter,  if  it  be  circular,  and  one 
fourth  if  longitudinal.  If  reasonable  success  is  to  be  attained,  it  is  necessary 
that  careful  attention  be  paid  to  every  aseptic  detail. 

Before  beginning  the  operation  empty  the  bladder,  and,  if  necessary, 
administer  an  anesthetic.     Local  anesthesia  will  commonly  suffice. 

The  Operation. — A  sound  is  introduced  into  the  urethra,  and  the  handle 
given  in  charge  of  an  assistant.  The  edges  of  the  opening  are  carefully 
pared  obliquely  from  without  inward,  and,  when  completed,  should  present 
a  funnel-shaped  appearance,  the  apex  corresponding  to  the  mucous  opening 
of  the  canal ;  undercutting  is  then  done,  dividing  the  tissues  into  two  sepa- 


OPEliA'riU.NS   UN    Till';   SCICOTL'.M    AM)    I'ENIS. 


1245 


rate  planes  (Fig.  148(!).  The  wound  is  then  closed  longitudinally  by  uniting 
oac'ii  layer  separately  (Fig-  14ST),  the  former  with  catgut,  the  latter  with 
horsehair,  silkworm  gut,  or  silk  (Fig.  1488).  Closure  without  undercutting, 
by  means  of  silkworm  gut,  horsehair,  or  antiseptic  silk 
sutures  carried  down  to,  but  not  through,  the  mucous 
lining,  the  intervals  between  them  being  short,  may  be 
made  (Figs.  1489  and  149U). 

The  After-treatment. — The  patient  should  be  kept 
quiet  and  given  alkaline  and  demulcent  drinks,  and  the 
urine  drawn  with  a  catheter.  It  is  a  wise  precaution  to 
inject  aseptic  oil  into  the  urethra  before  the  introduction  of  the  catheter. 
The  catheter  may  be  introduced  before  the  sewing,  and  allowed  to  remain 


Fiu,  I486.— U  rot  liror- 
rhapliy.  Tissues 
luulorcut,  sepa- 
niletl.  and  prc- 
parccl  I'or  sewing. 


k 


K 


Fig.  1487.— Urethror- 
rhaphy.  Deep  lay- 
er of  tissue  united, 
shown  transversely 
and  lonsritudinallv. 


Fig.  1488.— Urethror- 
rhaphy.  Deep  and 
superficial  tissues 
closed,  shown  t  rans- 
versely  and  longi- 
tudinallv. 


Fig.  1489. — Closing  large  ure- 
thral fistula.  Oval  freshen- 
ing. 


as  a  guide  to  the  latter,  and  for  the  escape  of 
urine  thereafter,  as  long  as  advisable. 

Tlte  Comments. — The  ill  effects  of  the  con- 
tact of  urine  with  the  freshened  borders  of  the 
opening  emphasizes  the  wisdom  of  the  establish- 
ment of  perineal  drainage  during  the  healing, 
unless  especially  contra-indicated.  However,  in 
some  cases,  the  catheter  can  be  borne  by  the 
urethra  long  enough  to  allow^  the  wound  to 
heal,  thus  avoiding  the  perineal  element  of  the 
case.  If  the  catheter  be  well  borne,  its  use  may 
be  supplemented  by  a  rubber  tube  extending 
from  it  to  a  vessel  beneath  the  bed. 

Urethroplasty. — Urethroplasty  is  employed 
to  close  larger  openings  than  those  within  the 
domain  of  urethrorrhaphv. 

If  flaps  be  dissected  upon  either  sUle  of  the  '^Th.ifflsMi'^t^iS  So" 
opening,  and  drawn  together  and  joined  in  the      ders  and  lateral  flaps. 


1246 


OPERATIVE   SURGERY. 


median  line,  imperfect  union  is  very  apt  to  result  on  account  of  their  thin- 
ness, median  contact,  and  from  sluggish  granulation  process. 

Nekton's  Method  (Fig.  1491). — In  Nekton's  method  the  edges  of  the 
opening  are  tirst  pared,  and  then  the  integument  is  detached  subcutaneously 
for  about  an  inch  around  it  by  entering  a  long,  thin  knife  blade  through  a 
transverse  cut  just  below  the  opening.  The  liberated  integument  is  then 
joined  in  a  longitudinal  fold  along  the  median  line  by  means  of  quilted 
sutures. 

Dieffenbach  (Fig.  1492),  instead  of  dissecting  subcutaneously,  raised  two 
parallel  longitudinal  flaps,  and  fastened  the  middle  of  their  raw  under  sur- 
faces together  by  sutures  passed  through  leather  supports  at  each  side.  Two 
or  three  rows  of  sutures  can  be  used  instead  of  this  method  of  apposition. 

Delpecli  dissected  up  a  single  flap,  drew  it  across  the  fistula,  and  fastened 
it  to  a  raw  surface  prepared  on  the  opposite  side.  Arlcmd  made  two  trans- 
verse flaps,  one  in  front  and  the  other  behind  the  fistula,  about  an  inch  and 
a  half  in  width.  The  anterior  one  was  dissected  up  toward  the  glans  about 
three  fourths  of  an  inch,  and  the  posterior  one  back 
over  the  scrotum,  until  it  could  be  easily  drawn  for- 
ward so  as  to  cover  the  fistula.  The  cutaneous  sur- 
face of  the  anterior  portion  of  the  scrotal  flap  was 
freshened  and  the  flap  drawn  forward  so  as  to  cover 
the  fistula,  and  the  anterior  flap  drawn  backward 
over  it  and  united  by  sutures. 


Fig.  1491. — Urethroplasty, 
Nelaton's  method. 


Fig.   1492.— Urethroplasty, 
Dieffenbach's  method. 


Fig.  1493.— Urethroplasty, 
Rigaud"s  method. 


BUjaud  (Fig.  1493)  closed  a  large  fistula  at  the  peno-scrotal  junction  by 
the  method  employed  by  Nekton  in  the  treatment  of  epispadias.  A  quadri- 
lateral median  flap,  with  its  base  adjoining  the  opening,  was  taken  from  the 
scrotum,  turned  forward  over  the  fistula,  and  its  raw  surface  covered  by  two 
flaps  taken  from  the  sides  and  drawn  together  so  as  to  meet  in  the  median 
line. 

Dittel's  Method  {hy  flap  sliding).— According  to  Dittel,  when  the  fistula 
lies  in  the  neighborhood  of  the  scrotum,  it  is  easy  to  draw  the  scrotal  skin 
over  it.  But,  should  the  posterior  angle  of  the  coapted  surfaces  be  exposed 
to  urinary  infiltration,  it  would  be  better  to  employ  a  skin  flap  which  has 
been  liberated  from  the  subcutaneous  tissues. 


()I'i:i;a'ii()Ns  on  tiik  scijoit.m  and  I'KNIs.  i-^il 

The  operatiun  \a  jJcrfurniL-il  us  follows  :  A  lur;,fe  iiieUil  sound  is  introduced, 
putting  the  urethra  and  fistula  opening  on  the  stretch.  The  sear  tissue  around 
the  fistula  is  trininied  away,  so  that  the  resulting  freshened  surface  has  an 
ohlong  shajie,  its  long  diameter  lying  transversely  to  the  long  axis  of  the 
penis.  An  incision  2)arallel  with  the  posterior  margin  of  the  wound  is 
uow  made  through  the  scrotal  skin,  which  is  distant  from  the  fistula  one 
to  one  and  a  half  inch,  according  to  the  size  of  the  denuded  area.  The 
flap  thus  outlined  is  dissected  up  from  the  subcutaneous  tissues,  forming  a 
transverse  bridge  of  skin  which  is  slid  forward  over  the  area  to  be  covered. 
The  anterior  margin  of  the  bridge  is  joined  to  the  anterior  margin  of  this 
area  by  means  of  button  sutures.  The  posterior  slit  is  left  open,  or  is  used 
in  so  far  as  to  introduce  a  soft,  thin  catheter  for  the  purpose  of  raising  the 
hinder  margin  of  the  bridge  and  protecting  the  wound  from  urinary  infil- 
tration. After  the  llu})  has  united  anteriorly,  the  posterior  slit  is  freshened 
up  and  its  edges  united  in  a  manner  similar  to  that  already  described. 

Operation  by  Flap  Transplantation. — In  refreshening  the  edges  of  the 
fistula  in  this  operation,  a  long  oval  shape  is  given  to  the  denuded  area. 
A  flap,  the  size  of  which  somewhat  exceeds  that  of  the  area  to  be  covered,  is 
formed  from  the  scrotal  integument,  its  base  situated  either  quite  at  the  pos- 
terior end,  or  else  near  one  side  of  the  refreshed  oval  surface.  In  the  former 
instance  the  flap  is  swung  around  ou  its  pedicle,  as  is  a  flap  from  the  skin 
of  the  forehead  in  rliinoplasty.  In  the  latter,  the  flap  is  exposed  to  a  mod- 
erate tension.  The  flap  is  sewed  in  position  by  means  of  button  sutures. 
After  union  has  taken  place  at  its  free  extremity  a  secondary  operation  is 
performed  for  closure  of  the  opening  at  the  base  of  the  flap,  and  for  the 
proper  treatment  of  the  pedicle. 

Urethrostomy. — Poncet  exposes  an  incurable  stricture  through  a  median 
incision  in  the  usual  manner,  divides  the  urethra  transversely  at  the  proxi- 
mal side  of  the  constriction,  slits  the  under  surface  of  the  central  stump 
for  a  short  distance,  and  stitches  it  to  the  lower  angle  of  the  cutaneous 
wound.  The  end  of  the  peripheral  urethral  stump  is  sutured,  dropped 
into  the  wound,  which  is  then  closed  and  stitched  down  to  the  perineal 
opening. 

Perineal  Urethroplasty. — Perineal  urethroplasty  has  been  practiced  in 
the  repair  of  the  gap  in  the  urethra  following  urethrectomy  for  extreme  stric- 
ture and  for  partial  or  complete  rupture  of  the  urethra.  WiJlfJe?'  removed 
the  cicatricial  area  of  a  strictured  urethra,  and  covered  the  granulating  surface 
with  mucous  membrane  taken  from  a  prolapsed  uterus,  the  same  as  Thiersch's 
skin  grafts  are  applied.  The  tissue  was  kept  in  place  with  lubricated  iodo- 
form gauze.  Several  successful  results  of  this  nature  are  reported.  Keyes 
secured  a  partial  success  by  grafting  the  inner  layer  of  the  prepuce.  In  not  a 
few  instances,  when  due  to  rupture  (page  1253)  or  excision  of  a  stricture,  the 
urethra  has  been  repaired  by  the  union  of  the  divided  ends  over  a  catheter 
with  catgut  or  silk  sutures  (Figs.  1502  and  1503).  Weir  reports  two  such 
cases  as  successful  with  silk  sutures  and  suprapubic  drainage  in  urethral 
rupture.  Robson  reports  a  success  in  a  case  of  urethrectomy  for  stricture  by 
continuous  cats^ut  sewing  of  the  divided  extremities  over  a  catheter. 


Fig.  1494. — Instruments  employed  in  perineal  section  and  conditions  requiring  it. 
a.  Perineal  drainage  tube  with  tapes,  b.  Bistouries,  straight  and  blunt,  c.  Bistoury, 
blunt-pointed,  d.  Blizard's  lithotomy  knife,  e.  Traction  loops.  /.  Tunneled  staflf. 
g.  Tunneled  catheter  and  stylet.  /(."  Small  gum  catheter,  i.  Long  silyer  probe. 
j.  Banks's  whalebone  dilator  and  a  whalebone  guide,  k.  Flexible,  gum,  bulbous  bou- 
gies, assorted  sizes.  I.  Otis's  metallic  bulbous  bougies,  assorted  sizes,  vt.  Grooved 
staff.  ?i.  Steel  sound,  o.  Scissors,  short  blunt-pointed,  straight  and  curyed.  p. 
Brown's  flushing  director,  q.  Teale's  gorget,  r.  Arnot's  fine  director,  s.  Large 
curved  needle  and  silkworm  gut.  /.  Thumb  and  mouse-tooth  forceps.  «.  Glass  penis 
syringe,  v.  Forci pressure,  w.  Grooved  director,  x.  Female  catheter,  y.  Blunt 
and  hooked  retractors,  z.  Scale  for  determining  size  of  bougies  and  sounds.  Wipers, 
ligatures,  and  gauze  should  be  provided. 
1248 


OI'KIJATIONS   ON    TllK   SCKUTLM   AND    I'ENIS. 


1249 


The  General  Remarks. — After  these  operations  the  urine  should  be  kept 
bland  by  a  free  use  of  diluents  and  other  correetive  remedies.  The  parts 
should  be  kept  thoroughly  cleansed  and  free  from  misdirected  handling. 
Incurving  is  due  in  part  to  shortening  of  the  capsule  of  the  corpora  cav- 
ernosa and  perhaps  of  the  fibrous  septum,  and  considerable  time — five  or  six 
months — may  pass  before  the  tendency  to  return  of  this  deformity  disap- 
pears. Tlie  muco-cutaneous  ridge  corresponding  to  the 
absent  urethra  must  be  divided  transversely  in  a  subcu- 
taneous or  open  manner.  DtipJay  commends  the  latter, 
advising  that  they  be  carried  to  some  depth  and  the 
borders  united  longitudinally,  thus  overcoming  the 
curvature. 

External  perineal  urethrotomy  (Gouley),  sometimes 
called  perineal  section,  is  employed  in  the  treatment  of 
intractable  strictures,  especially  when  accompanied  by 
a  urethral  fistula  located  in  the  perineum  and  for  rup- 
ture of  the  urethra.  External  perineal  urethrotomy 
may  be  performed  either  icith  or  icifhout  a  guide  and 
under  thorough  asepsis.  The  former  is  not  a  difficult 
operation,  while  the  latter  is  frequently  an  extremely 
perplexing  one.  Syme's  grooved  staff  (Fig.  1405)  is  ob- 
jectionable, in  that  its  point  may  get  into  a  false  passage 
and  the  stricture  be  missed.  Moreover,  its  introduction 
through  the  stricture  is  more  diliicult  than  that  of  the 
whalebone  guide,  and  is  attended  by  greater  danger  to 
the  soft  parts.  If  the  ordinary  small-sized  grooved  staff 
employed  in  lithotomy  can  be  introduced,  nothing  better 
than  this  need  be  desired. 

21ie  Operation  with  a  Guide  (for  Stricture). — Evac- 
uate the  bowel,  shave  and  cleanse  the  perinaeum,  admin- 
ister an  anaesthetic,  disinfect  and  fill  the  urethra  with 
aseptic  olive  oil,  locate  the  seat  of  the  stricture,  and 
introduce  a  whalebone  guide  into  the  bladder  in  tlie 
manner  before  described  (page  420) ;  over  this  pass  the 
grooved  or  tunneled  catheter  staff  down  to  and  through 
the  stricture  (Fig.  130T),  if  it  can  be  done  readily ;  if 
not,  allow  its  beak  to  rest  against  the  obstruction,  the 
instrument  being  carefully  supported  by  an  assistant, 
who  at  the  same  time  raises  and  holds  the  scrotum. 
The  patient  is  now  placed  in  a  lithotomy  position,  and 
the  limbs  supported  by  an  assistant  upon  either  side.  The  surgeon,  sitting 
upon  a  low  stool  facing  the  perinfeum  of  the  patient,  introduces  the  left 
index  finger  into  the  rectum  to  ascertain  the  condition  of  the  membranous 
and  prostatic  portions  of  the  canal.  A  free  incision,  from  an  inch  to  an  inch 
and  a  half  long,  is  then  made  in  the  median  line  of  the  perinffium,  extend- 
inor  from  the  base  of  the  scrotum  to  witliin  half  an  inch  of  the  anus,  through 
the  integument  and  fascia.     The  grooved  instrument  is  carefully  located  by 


Fig.  1495. — Syme's 
grooved  staff. 


1250 


OPEEATIVE  SURGERY. 


the  finger,  and  the  urethra  bronglit  into  view  by  repeated  cuts  in  the  same 
line.     The  nail  of  the  index  finger  assures  the  surgeon  of  the  location  of  the 

groove,  and  tlie  urethra 


is  divided  longitudinally 
upon  it.  Two  silk  trac- 
tion loops  are  now  passed, 
one  through  each  bor- 
der of  the  divided  ure- 
thra, and  are  given  in 
charge  of  assistants,  who 
are  instructed  to  care- 
fully draw  the  lips  of 
the  wound  apart  (Fig. 
1496).  This  important 
step  exposes  the  mucous 
wall  of  the  urethra  com- 
pletely, enabling  the 
operator  to  follow  its 
course  by  carefully  ob- 
serving the  continuity 
of  its  structures.  The 
staff  is  now  withdrawn 
sufficiently  to  expose  the 
black  whalebone  guide, 
then  the  beaked  bistoury 
(Fig.  1498)  is  intro- 
duced in  its  course,  and 
the  stricture,  together  with  about  half  an  inch  of  the  canal  immediately 
behind  it,  is  divided  in  the  median  line. 

The  entrance  of  a  grooved  director  or  a  small  gum  catheter  through  the 
opening  into  the  bladder,  followed  by  the  flow  of  urine,  assures  the  surgeon 
that  the  proper  channel  is  located  ;  or,  after  the  division  of  the  stricture,  the 
tunneled  catheter  (Fig.  1307)  may  be  passed  along  the  whalebone  guide  into 
the  bladder,  and  the  stylet  withdrawn,  when  the  diagnostic  urinary  stream 
will  appear.  The  instruments  are  now  withdrawn  from  the  urethra,  and 
the  ordinary  sound  of  suitable  size  is  introduced  through  the  urethra  into 
the  neck  of  the  bladder,  to  determine  the  complete  freedom  of  the  passage. 

The   Remarks. — The  passage  of   bulbous   bougies  (Figs. 
1494  and  1507),  with  the  object  of  determining  the  number, 


Fig.  1496. — The  operation  of  external  j)enneal  urethrotomy. 
Grooved  stall:  seen  between  separated  borders  of  incisions. 


HE 


Pig.  1497. — Banks's  dilating  filil'orni  bougies. 

location,  size,  and  resiliency  of  the  strictures  (page  1255),  should  be  prac- 
ticed, thus  establishing  the  need  of  a  more  active"  operative  treatment  than 


OrEUATIUNS   UN    THE   SCKOTL'M    AM)    I'KNIS 


1251 


? 


I 


S 


Fig.  1498.— Gouley' 
beaked  bistourv. 


Fio.  1499.— Gouley's 
grooved  director  (c) 
and  tenaculum  (e). 


that  by  the  use  of  sounds.  'I'lie  whalebone  liliform  bougies  of  lianks 
(Figs.  14'J7  uiul  loUT)  are  so  sliapod  above  as  to  readily  overcome  u  stric- 
ture through  which  the  advancing  end  has  already  passed  far  enough  for 
the  purpose.  However,  great  care 
should  be  exercised  in  their  use,  or 
harmful  results  will  (piite  surely  fol- 
low. The  beaked  bistoury  of  Gou- 
ley (Fig.  14'J8),  the  grooved  director 
(Fig.  14yii,  <•),  and  small  sharp  te- 
naculum (Fig.  14'.»li,  e),  are  of  spe- 
cial aid  in  this  oi)eration.  .Some- 
times a  small  invaginated  catheter 
(Fig.  1500)  will  find  a  way  along 
devious  channels  of  suitable  dimen- 
sions that  can  not  otherwise  be  trav- 
eled. This  agent  is  of  much  greater 
utility  in  connection  with  retention 
of  urine  from  prostatic  enlargement 
(page  1114)  than  when  associated  with 
perplexing  false  passages.  It  is  evi- 
<lent  at  once  that  the  invaginated  catheter  will,  after  its  escape,  point  a  dif- 
€rent  course  than  that  of  the  external  one,  and  therefore  gain  prompter 
admission  to  the  bladder. 

21ie  Operation  without  a  (iuide. — After  all  efforts  to  introduce  a  whale- 
bone guide  (Fig.  1501)  into  the  bladder  have  failed,  pass  the  tunneled  cathe- 
h      ter  staff  (Figs.  1304,  ^,  and  1309)  over  a  whalebone  guide  along  the 
urethra  as  far  as  it  will  go  without  using  violence ;  then  place  the 
staff  and  guide  in  charge  of  an  assistant  as  before.     Make  an  incision 
of  the  usual  length  directly  in  the  median  line  down  to  and  through 
the  urethra  into  the  groove  at  the  end  of  the  staff;  pass  the  silken 
loops  through  the  borders  of  the  incised  urethra  as  before  (Fig. 
149G)  ;  check  all  haemorrhage,  withdraw  the  staff  slightly,  and 
examine  to  see  if  it  be  located  in  the  urethral  tube.     The 

Ji  lips  of  the  urethral  in- 
cision are  now  drawn 
well  apart,  and  the 
operator,  whose  pa- 
tience, care,  and  knowl- 
edge must  now  be  well  tested,  endeavors  to  introduce  a  whalebone  guide,  or 
a  fine  probe,  or  a  small  grooved  director  (Fig.  1409.  c)  through  the  stricture 


Fig.  1.500. — Mercier's  inva_'inat«'d  catht-ter. 
a.  Retaining  catheter.     6,  b.  Invaginated  catheter 


J 


r 


Fig.  1501. — Goulev's  whalebone  guides,  full  lengths  (Fig.  1.306i. 


into  the  bladder  by  way  of  the  perineal  incision.     If  the  effort  be  successful 
the  remainder  of  the  operation  is  simple,  and  consists  only  in  dividing  the 


85 


1252 


OPEllATIVE   SURGERY. 


Fig.  1o02. — Incomplete 
rupture  of  ni-ethra 
with  catheter  in  the 
cjinal  preparatory  to 
sewing. 


J^iG.  1503. — Incomplete 
rupture  of  urethra 
being  sutured  over 
catheter. 


stricture  with  the  beaked  (Fig.  1498)  or  a  probe-pointed  bistoury  from  above 
downward  as  before ;  usually,  however,  no  anterior  opening  can  be  found,  or 
one  may  be  detected  which  leads 
away  from  the  median  line,  show- 
ing the  existence  of  a  false  passage. 
In  either  case  the  plan  of  the 
operator  must  be  the  same.  Keep 
in  the  median  line.  If,  after  a 
patient  search,  no  direct  orifice  be 
found,  it  is  often  possible  to  de- 
tect it  by  making  moderate  pressure  above  the  pubes  on  the  bladder,  which 
will  frequently  cause  a  few  drops  of  urine  to  escape  from  the  obscure  open- 
ing in  the  perineal  cut,  into  which  a  whalebone  guide  or  a  fine  director  can 

be  inserted,  and  usually  passed  into 
the  bladder.  Ilot-water  injection 
into  the  wound  will  sometimes  reveal 
the  urethra  by  emphasizing  its  paler 
color.  If  nothing  is  accomplished  by 
either  of  these,  then  the  stirgeon  feels 
for  the  opening  in  the  triangular 
ligament  (Fig.  1379),  through  which 
the  urethra  normally  passes,  and  cuts 
toward,  and  even  through  it  if  the 
urethra  can  not  be  found  before.  As 
he  cuts  he  repeatedly  seeks  for  the 
orifice,  and  closely  examines  for  a 
continuity  of  the  fibrous  mass  in  the 
line  of  his  incision  with  the  tissues 
composing  the  walls  of  the  urethra. 
In  the  obscure  division  of  the  amal- 
gamated perineal  tissues  the  surgeon 
is  also  guided  by  the  established  re- 
lations of  the  normal  urethra  to  the 
arch  and  rami  of  the  pubes,  to  the 
tuberosities  and  rami  of  the  ischium 
(Fig.  1378  and  page  1182),  and,  still 
more  important,  the  relations  to  the 
^  rectum.      The   careful  cutting  and 

Fig.  1504. — Complete  rupture  of  urethra,  searching  are  continued  until  an 
proximal  end  found  Introduction  of  opening  is  found  which  leads  into 
catlieter  preparatory  to  sewing,     a.  Dis-    ^,      ,  ,  "^  ,  mi      x-  i        •        ^^ 

tal  end  of  rupture,  h.  Proximal  end  of  the  bladder.  Ihe  tissue  barring  the 
rupture  held  open  by  forceps  for  intro-  passage  is  cut,  and  a  small  gum  cathe- 
duction  of  catlieter  (c).     d.  Catheter  in-    :        .  ,      ,  , ,  ,  ,. 

troduced  into  urethra.  ter  is  passed  along  the  probe  or  di- 

rector into  the  organ.  This  act  is 
followed  by  the  welcome  flow  of  urine.  The  catheter  is  then  withdrawn, 
the  canal  dilated  gently,  and  all  constricting  bands  at  the  roof  and  floor  of 
the  urethra  are  severed.     A  steel  sound  the  size  of  the  canal  is  then  intro- 


()I»KI{ATI()\S   ON   THK   SCKo'ITM    AM)    I'KNIS. 


12r)3 


duced  into  the  l)l;i(l(lc'i-  tlii-(ju;,di  the  urt'tliru  until  its  iiiiiiitcn'iijitfd  oiitriiiico 
is  iissiiri'd.  Tlu'  si/i'  of  tlu;  im-aliis  is  iiicrcascd,  and  all  ohslinatc  stricturi'S 
in  front  of  tlic  pi'iincal  o[»t'nini,f  divided  hy  internal  uretlii'otoiny.  Exanune 
the  bladder  for  stone,  and  if  found  remove  it;  stop  all  bleeding. 

In  n(/)fi(rc  of  the  lorf/ira,  oecasionall}'  a  catheter  or  stall  may  be  ])assed 
quite  reailily  into  the  bladder.  Hut  in  instances  of  complete  rupture  from 
bruising  of  the  j)erinitMun,  or  incomplete  rupture  complicated  with  narrow 
stricture,  this  measure  can  not  be  uccomplished  at  once,  if  at  all,  especially 
in   a  ease  of   the  former 


condition.  In  ruj)turc 
from  bruising,  a  free  in- 
cision into  tlic  i)erinanim 
is  made  in  the  median 
line  down  upon  the  con- 
vexity of  a  grooved  staff 
(page  119"^),  if  introduced 
into  the  bladder ;  if  not, 
upon  the  advanced  end, 
thus  exposing  the  seat  of 
the  injury  and  permitting 
of  the  elimination  of  the 
blood  clots  and  extrava- 
sated  urine.  The  bleed- 
ing is  then  arrested  and 
the  injury  of  the  urethra 
found.  If  the  rupture  be 
incomplete  the  urethra  is 
treated  as  in  external  ure- 
throtomy for  other  causes 
(page  1294  ei  seq.),  or  re- 
paired in  a  manner  in- 
dicated (Figs.   1502    and 

1503).    If  the  rupture  is  t^      .-„^     ^,       ,  ,        ,        ,      ,,             •      i      i     ^ 

'                  Toi  -'^^^'  15"'5' — Complete  ruj)ttu-c  01  uretlira,  proxuiial  end  not 

complete  no  difficulty  at-  fouiul,  retrograde  catheterism.     Iiilroduction  of  cathe- 

tends    the    recognition   of  ter  preparatory  to  sewing,  a  retrograde  introduction 

.  practiced  only  when  the  proxniial  riiptiu'ed  end  can 

the  distal  extremity  of  the  ,n,t  be  foumrfor  the  puri)Ose  of  sewing.     Suprapubic 

canal,   as    the   instrument  opening  utilized  for  drainage,     a.  Extremity  of  intra- 

^,            ,    .,  vesical  catheter,    i,  J.  Extremities  of  catheter  in  penis. 

is  seen  passing  through  it.  c.  Wall  of  blad.ler. 

The  finding  of  the  proxi- 
mal end,  however,  is  often  tedious  and  difficult,  requiring  the  same  care  and 
scrutiny  that  characterizes  its  discovery  in  perineal  urethrotomy  without  a 
guide  (page  1252).  After  securing  the  proximal  end  repair  can  be  effected 
by  sewing  over  a  catheter  introduced  for  the  purpose  (Figs.  1502,  1503,  and 
1504).  When  the  proximal  end  can  not  be  found  the  blood  and  urine  usually 
will  readily  escape,  and  the  danger  of  further  extravasation  will  be  prevented. 
However,  if  plastic  repair  of  the  urethra  be  contemplated,  or  retention  of 
urine  be  likely  to  happen,  it  will  be  necessary  to  open  the  bladder  above  the 


1254  OPERATIVE  SURGERY. 

pubis  (Fig.  1312)  and  practice  retrograde  adheterism  to  prevent  the  latter; 
also  to  accomplish  the  former  2)urpose  (Fig.  1505). 

The  Precautions. — Carefully  avoid  injury  of  the  structures  by  persistent 
efforts  in  passing  a  catheter  or  staff.  Operate  promptly  to  prevent  needless 
extravasation  of  urine  and  consequent  sup])uration  and  fistula3.  Extravasa- 
tion between  the  layers  of  the  triangular  ligament  (Figs.  1374  and  1379) 
and  beneath  the  superficial  perineal  fascia  do  not  cause  tumefaction  until 
after  rupture  of  the  fascial  restraints  and  the  consequent  extended  infiltra- 
tion (page  1182).  It  should  not  be  overlooked  that  a  catheter,  while  plugged 
with  blood,  when  introduced  into  the  bladder  through  the  proximal  end  of 
a  ruptured  urethra  will  not  permit  urine  to  escape ;  otherwise  it  may  be 
thought  that  the  instrument  has  gone  astray.  However,  if  the  eye  of  the 
instrument  be  cleared  by  a  stream  of  water,  and  other  facts  relating  to 
catheterism  of  the  bladder  already  noted  (i)age  1110)  be  heeded,  tiiis  per- 
plexity will  be  speedily  removed. 

The  Results. — In  29  reported  cases  of  rupture  of  the  urethra  treated  by 
immediate  suture,  all  are  announced  as  successful.  These  results  are  aston- 
ishing and  commend  repetition. 

The  After-treatment. — Place  the  patient  in  bed  with  hot  fomentations  to 
the  abdomen  ;  elevate  the  scrotum  to  prevent  infiltration  ;  administer  ano- 
dynes and  demulcents,  and  keep  the  patient  quiet.  The  major  portion  of 
the  perineal  wound  may  be  closed  by  sutures  carried  deeply,  leaving,  how- 
ever, sufficient  room  for  the  introduction  of  a  large,  flexible  catheter  through 
the  neck  of  the  bladder,  which  is  fastened  in  place  by  means  of  tapes  (Fig. 
1494).  It  is  allowed  to  remain  in  position  for  four  or  five  days,  unless  its 
presence  causes  some  degree  of  vesical  irritation.  The  wound  should  be 
dressed  antiseptically.  The  catheter  should  be  kept  clean  by  regular  anti- 
septic injections  and  not  allowed  to  extend  too  far  into  the  bladder.  After 
removal  of  the  instrument,  regular  catheterization  at  short  intervals  should 
be  practiced  for  a  time.  The  use  of  boric  acid  or  salol  urotropen  for  urinary 
sterilization  is  important.  Suitable-sized  sounds  should  be  passed  every  two 
or  three  days  for  a  considerable  time  at  a  later  period,  in  order  to  gain 
a  urethra  of  the  normal  caliber  and  thus  secure  closure  of  the  perineal 
opening. 

The  Resiilts. — -In  8,000  cases  of  external  urethrotomy  performed  some 
years  ago,  a  little  over  5  per  cent  died.  Stricter  aseptic  measures  have 
lessened  this  rate. 

Internal  Urethrotomy. — Internal  urethrotomy  consists  in  the  division  of 
strictures  by  cutting  instruments  introduced  within  the  urethra.  The 
division  may  be  made  from  before  backward  or  from  behind  forward,  de- 
pending on  the  extent  of  the  stricture  and  the  inclination  of  the  surgeon. 
Ordinarily  they  are  cut  from  behind  forward.  The  roof  or  the  floor  of  the 
urethra  may  be  divided  in  either  instance,  the  division  of  the  former  being 
regarded  the  safer  and  better  procedure.  Thorough  asepsis  should  be  prac- 
ticed in  all  cases. 

Internal  urethrotomy  should  be  limited  to  strictures  of  the  penile  por- 
tion.    The  subpubic  strictures  and  those  of  the  membranous  portion  should 


OI'KKATIONS   UX    'I'llK   SCUO'I'l'.M    AND    I'KNIS. 


1255 


bo  divided  tlirouj^'h  the  jxTiiui'iiiii.      I'lie  iiiniibcr,  si:.(\  locdtio/i,  a/id  ixhitl  of 
till'  obstructions  should  he  di'tcrniincd  before  tlieir  division  is  iitteinpted. 
If  it  be  the  iuteiititm  of  the  operator  to  distend  tlie  canal  to  its  fullest 

capacity,  and  if  the 
meatus  be  undersized, 
the  hitter  should  be  en- 
larged before  the  stric- 
Yu;.\:m\.—i'\\\A^'shistoHric<trh'.  ture    is   divided.       Vax- 

largeinent  can  be  easily 
accomplished  by  means  of  the  bislouri  cache  oi  ('iviale  (I"'ig.  150G).  After 
properly  distending  tiie  meatus  the  bistoury  is  introduced  with  the  cutting 
surface  downward,  and  quickly  withdrawn.  'I'he  ordinary 
probe-pointed  bistoury,  or  a  straight-edged  one,  with  the  end 
guarded,  will  accomplish  the  purpose  perfectly.  The  lips  of 
the  cut  will  unite  unless  they  be  ke{)t 
separated  by  aseptic  lint  or  cotton, 
or  by  the  occasional  introduction  of 
a  large-sized  sound.  The  location, 
number,  and  size  of  strictures  can 
be  determined  by  the  introduction 
of  metallic  (Fig.  1507)  or  gum- 
elastic  (Fig.  1494)  bulbous  bougies 
of  assorted  sizes.  One  of  large  size 
that  will  slip  through  the  meatus 
is  selected,  oiled,  and  passed  down 
the  canal  until  arrested.  The  dis- 
tance in  the  canal  is  noted  on  the 
handle.  It  is  then  withdrawn,  and 
the  size  of  the  bulb  measured  by 
the  familiar  scale. 

The  surgeon  next  ascertains  the 
size  of  the  bougie  that  will  pass 
the  obstruction,  and  so  on,  record- 
in  jr  the  location  and  size  of  each 
obstruction  in  its  turn  until  the 
bladder  is  entered.  The  urethrom- 
eter  of  Otis  (Fig.  1508)  is  con- 
structed on  a  principle  calculated 
to  give  practically  accurate  measure- 
ments. The  unexpanded  blades  of 
the  extremity  of  the  instrument,  i, 
are  covered  by  a  small,  thin  rubber 
cap,  c;  the  instrument  is  oiled  and 
carried,  closed,  through  the  last  ob- 
struction, if  possible,  when  the  ex- 

tremitv  is  expanded  by  a  screw  at  the  outer  end  until  it 
fills  the  urethra,  the  capacity  of  which  is  noted  upon  the 


Fig.  1507.— Otis's  Ijougies     Fio.    lodS.— Otis's 
a  boule  (metallic).  urethrompter.  a. 

Blades  exiiand- 
ed.  b.  Blades 
unexpanded.  c. 
Rubber  cap. 


1256 


OPERATIVE  SURGERY. 


dial;  it  is  slowly  withdrawn  while  the  expanding  extremity  is  regulated  to 
accommodate  the  varied  dimensions  of  the  canal,  the  caliber  of  which,  in  the 

different  locations,  should  always  be  noted. 
By  this  simple  though  ingenious  method 
the  surgeon  is  enabled  to  locate  quite  cor- 
rectly the  seat  and  caliber  of  the  obstacles 
he  is  to  treat. 

Urethrotomes,  like  other  instruments  de- 
signed for  special  purposes,   vary  in    many 


Fig.  150'J. — Utis's  curved 
urethrotome,  expanded 
and  closed. 


Fig.  1510.— Otis's  straight 
urethrotome,  expanded. 


Fig.  1511. — Peet's  urethro- 
tome, expanded. 


important  particulars.  Those,  however,  of  greatest  practical  utility  were 
devised  by  Otis  and  by  Peet  (Figs.  1509,  1510,  and  1511).  Each  bears 
upon  its  handle  a  scale  which  enables  the  operator  to  ascertain  not  only  the 
size  but  the  disteusibility  of  an  obstruction.  Either  of  these  instruments 
when  taken  in  connection  with  the  urethrometer,  enables  the  surgeon  to 


OPERATTONS   OX   THE   SCROTUM    AND    I'KNl.S.  1^57 

divide  the  strictured  j)arts  until  tlie  scale  on  the  dial  or  handle  of  the  cut- 
ting instrument  indicates  that  the  strictured  portions  of  the  urethra  corre- 
spond in  size  to  the  dimensions  of  the  normal  portions,  as  already  indicated 
by  the  dial  of  the  urethrometer. 

The  (Jperation. — After  cleansing  the  urethra  a  general  anaesthetic  or 
cocain  solution  is  employed,  and  the  patient  is  placed  upon  the  back.  Then 
a  well-oiled  aseptic  instrument  is  introduced,  and  the  extremity  conceal- 
ing the  blade  is  carried  beyond  the  obstruction,  which  is  dilated  by  turn- 
ing or  depressing  the  screw  at  the  end  until  the  strictured  tissues  are  made 
tense,  when  the  knife  is  withdrawn  sufficiently  to  divide  the  stricture 
freely.  The  action  of  the  instrument  is  tlien  reversed  and  the  knife  pushed 
back  into  its  hiding  place,  and  the  instrument  again  dilated  to  note  the 
effect  of  the  incision  upon  the  caliber  of  the  stricture.  If  the  caliber 
still  be  below  the  standard,  as  indicated  by  the  urethrometer,  incision  is 
again  made.  In  this  manner  eacii  constriction  can  be  divided  and  the 
urethral  tube  made  of  a  uniform  diameter  throughout.  If  two  or  more 
strictures  have  a  common,  or  an  almost  common,  diameter,  they  can  be  cut 
simultaneously  by  drawing  the  knife  along  the  course  of  the  shaft.  There 
is  little  danger  of  cutting  the  healthy  mucous  membrane  so  long  as  the  dial 
on  the  urethrotome  indicates  a  smaller  dimension  than  that  of  the  normal 
urethra,  as  shown  by  the  urethrometer. 

The  Complications. — If  severe  haemorrhage  follow,  a  large-sized  sound 
can  be  introduced,  and  the  penis  bandaged  to  it.  Cold  may  be  applied  by 
means  of  a  stream  of  iced  water  conducted  through  a  double-barreled  cathe- 
ter. It  is  sometimes  necessary  to  make  pressure  on  the  perinfeum,  in  con- 
junction with  other  expedients.  The  necessity  for  this  is  extremely  rare. 
Unless  aseptic  care  be  exercised  in  the  manipulations  directed  to  the  arrest 
of  hiemorrhage,  septic  poisoning  may  result. 

Tlie  After-treatment. — Following  urethrotomy  the  patient  must  be  kept 
•quiet  in  bed  for  three  or  four  days,  with  a  light  diet  and  open  bowels; 
demulcent  and  alkaline  drinks  are  often  advisable.  A  sound  may  be  passed 
every  third  day  until  tlie  wound  is  healed. 

The  Results. — Few  patients  perish  as  the  direct  result  of  internal  ure- 
throtomy, and,  when  carefully  done  upon  proper  cases,  an  unfavorable  result 
need  not  be  anticipated.  If,  however,  severe  bleeding  happen,  requiring 
urethral  manipulation  to  arrest  it,  septic  changes  may  be  caused  and  an 
unfavorable  outcome  result.  The  inclination  to  perform  internal  urethrot- 
omy has  abated  much  indeed  in  the  last  few  years,  and  wisely,  too,  as  it 
appears  to  the  writer.  The  paraphernalia  for  arrest  of  hemorrhage  arising 
from  too  free  or  incautious  division  of  strictures  is  so  suggestive  of  ominous 
outcome  in  many  cases  as  to  inspire  the  caution  in  division  that  has  been 
followed  by  more  conservative  action  and  consequently  a  lessened  rate  of 
disaster  from  complicating  causes. 

The  Tapping  of  the  Urethra  (Cock).— Tapping  the  urethra  in  a  distended 
bladder  from  impassable  stricture  is  a  feasible  operation  under  urgent  cir- 
cumstances- The  patient  is  placed  in  the  lithotomy  position,  and  the  left 
index  finger  introduced  into  the  rectum,  and  its  tip  pressed  against  the  apex 


1258 


OPERATIVE   SURGERY. 


of  the  prostate  (Fig.  1512).  A  double-edged  knife  is  then  plunged  into  the- 
perinaium  in  the  median  line,  the  point  being  directed  to  the  tip  of  the  fin- 
ger, and  caused  to  open 
the  urethra  in  front  of  the 
prostate,  behind  the  stric- 
ture, by  a  slight  lateral 
motion.  As  the  knife  is 
withdrawn,  the  dimensions 
of  the  wound  may  be 
increased  anteriorly.  A 
grooved  director  is  then 
carried  into  the  bladder 
through  the  opening,  and 
a  catheter  passed  upon  it 
to  relieve  the  distended 
viscus.  The  opening  may 
be  made  through  the  an- 
terior wall  of  the  rectum  when  objections  exist  to  the  perineal  puncturc 
The  knife  should  not  be  withdrawn  until  the  director  is  passed  into  the 
bladder,  otherwise  the  liiie  of  incision  may  be  lost.  Suprapubic  aspiration 
should  be  employed  in  place  of  rectal  and  urethral  tapping,  when  possible. 


Fig.  1512. — Tapping  urethra. 


MISCELLANEOUS    OPERATIONS. 

Psoas  Abscess. — Psoas  abscess  can  be  opened  directly  from  behind  with 
comparatively  little  danger,  and  with  the  attainment  of  good  drainage. 
Although  Israel  operated  first,  to  Treves  more  than  to  any  one  else  belongs 
the  credit  of  the  establishment  of  the  simplicity  of  the  operation  from  an 
anatomical  standpoint. 

The  Anatomical  Points. — The  width  of  the  erector  spinas  muscle  (about 
three  inches),  and  the  arrangement  of  the  lumbar  fascia  with  reference  to 
the  erector  spina?,  the  quadratus  lumborum,  and  the  psoas  magnus  muscles, 
and  to  the  borders  of  the  vertebra?,  should  be  carefully  noted  before  opera- 
tion (Figs.  1033  and  1034).  The  length  and  shape  of  the  transverse  processes 
of  the  lumbar  vertebrae  and  their  connections  should  be  recalled  also.  The 
detail  of  the  origin  of  the  psoas  magnus,  the  course  of  the  lumbar  vessels,  the 
relation  of  important  vessels  and  nerves  to  the  anterior  surfaces  of  the  bodies 
of  the  vertebrae,  are  of  much  importance  in  suggesting  the  limitation  of 
manipulative  measures. 

The  Operation  (Treves). — Make  a  vertical  incision  along  the  outer  border 
of  the  erector  s})ina?,  with  the  center  midway  between  the  iliac  crest  and  the 
last  rib  (Figs.  1032,  1033,  and  1034),  two  inches  and  a  half  in  length  down 
upon  the  lumbar  fascia ;  divide  the  fascia  and  expose  the  fibers  of  the  erector 
spina?  the  entire  length  of  the  incision  ;  separate  the  outer  border  of  the 
muscle  from  the  sheath,  and  draw  the  entire  muscle  toward  the  median  line 
with  retractors,  thus  exposing  the  anterior  layer  of  the  sheath — i.  e.,  the 
middle  layer  of  the  lumbar  fascia;  divide  the  anterior  layer  of  the  sheath 
vertically  as  near  to  its  connection  with  the  tips  of  the  transverse  processes 


IMISCKlil.ANKors   Ol'KKA'IMONS. 


ll^5<J 


Fig.  1513. — Instrmnonts  employed  for  operation  on  psoas  abscess. 

a.  Large  and  small  scalpels,  h.  Forcipressure.  c.  Short  blunt-pointed,  straight  and 
curved  scissors,  d.  Dressing  and  mouse-tooth  forceps,  e.  Blunt  and  hooked  retrac- 
tors, f.  Sponge-holder  with  sponge,  g.  Barker's  flushing  gauge,  h.  Long  curved 
needle",  i.  Grooved  director.  /.  Perforated  drainage  tube.  k.  Long  silver  probe. 
I.  Scoop,  m.  Catgut  ligatures.  Silkworm-gut  sutures,  wipers,  small  sponges,  band- 
ages, and  an  aspirating  needle,  etc.,  are  required. 

as  convenient,  thereby  exposing  the  quadratus  lumborum  muscle  (Fig. 
1032);  sever  the  muscular  fibers  close  to  the  end  of  a  transverse  process, 
and  enlarge  the  incision  cautiously  to  the  full  extent  of  the  wound  ;  divide 
the  anterior  layer  of  the  lumbar  fascia,  and  expose  the  outer  border  of  the 
psoas  magnns  muscle;  sever  some  of  the  tendinous  fibers  of  the  psoas  from 
the  transverse  process,  close  to  the  bone  anteriorly;  introduce  the  finger 
beneath  the  muscle  and  carry  it  gently  along  the  surface  of  the  process  to 
the  anterior  aspect  of  the  body  of  the  vertebra,  thus  entering  the  abscess 
cavity;  continue  the  exploration  with  the  finger  until  the  extent  and  con- 
dition of  the  vertebral  structures  are  determined  as  far  as  practicable.  Irri- 
gate the  abscess  cavity  with  a  solution  of  bichloride  of  mercury  (1  to  5,000), 
causing  the  fluid  to  come  in  contact  with  every  aspect  of  the  wall  by  manip- 


1260  OPERATIVE   SURGERY. 

Illation  and  change  of  the  position  of  the  patient,  and  repeat  the  emptying 
and  filling  of  the  abscess  cavity ;  remove  the  pyogenic  lining  by  scrai)ing 
with  the  fingers  also  isolated  collections  of  carious  matter;  instead  of  the 
fingers,  small,  fine  sponges  can  be  employed,  on  a  sponge  holder,  and  intro- 
duced into  every  part  of  the  cavity,  which  is  scoured  in  turn  by  vigorous 
to-and-fro  and  rotatory  movements  of  the  sponge.  The  flushings  and  spong- 
ing of  the  cavity  are  re{)eated  until  no  gross  evidences  of  disease  any  longer 
appear.  The  cavity  of  the  abscess  is  then  wiped  dry  with  sponges,  and  the 
wounds  are  closed  by  silkworm-gut  sutures  carried  deep  enough  to  include 
the  muscular  and  tendinous  structures.  An  aseptic  dressing,  secured  in  i)lace 
by  a  body  bandage,  completes  the  operation. 

Tlte  Fre(Mi(tions. — Care  should  be  exercised  in  cleansing  the  abscess 
cavity  not  to  encroach  on  the  thin  walls,  and  thus  injure  the  abdominal 
vessels  (Fig.  898).  A  close  adherence  to  the  spinous  processes  in  reaching 
the  abscess  insures  against  danger  of  injury  to  the  lumbar  arteries.  If  the 
incision  be  directed  too  far  outward,  the  peritoneal  cavity  may  be  opened. 

The  Remarlcs. — If  the  patient  be  thin,  the  seat  of  disease  is  easily 
reached;  if  very  stout,  much  difficulty  in  reaching  it  is  experienced,  and  it 
may  be  impossible  to  do  so  in  some  cases.  The  side  selected  depends  on 
convenience  of  operating  and  the  seat  of  the  preponderance  of  the  disease. 
The  right  side  is  somewhat  more  convenient,  but  this  is  not  of  sufficient 
moment  to  lead  one  to  disregard  the  importance  of  attacking  the  disease  at 
the  seat  of  the  greatest  development.  In  the  presence  of  marked  kyphosis, 
the  space  between  the  crest  of  the  ilium  and  the  last  rib  may  be  mnch 
reduced  and  even  almost  abolished.  The  flushing  gouge  of  Barker  already 
described  (Fig.  336,  d,  page  374)  can  be  used  to  cleanse  the  abscess  cavity  of 
the  products  of  disease.  Hot  water,  at  a  temperature  of  110°  or  113°  F.,  can 
be  used  in  washing.  The  introduction  into  the  cavity  of  the  abscess  of  the 
iodoform  emulsion,  followed  by  closure  of  the  wound,  and  antiseptic  dressing 
retained  in  place  undisturbed  for  a  week  or  ten  days,  is  often  followed  by 
prompt  healing  and  cure.  Incision  at  the  posterior  border  of  the  sterno- 
mastoid,  so  as  to  reach  the  brachial  plexus,  which,  as  a  guide,  leads  to  diseased 
bone  in  the  cervical  region,  has  been  practiced. 

The  After-treatment. — The  after-treatment  is  that  directed  to  the  cure 
of  Pott's  disease,  and  raises  the  question  of  absolute  rest  in  bed  for  an 
indefinite  time,  versus  the  use  of  artificial  support  with  out-of-door  advan- 
tages, a  question  which  can  not  be  discussed  here.  If  the  wound  does  not 
heal  at  once,  or  the  line  of  union  breaks  down,  the  washing-out  and  scrub- 
bing process  can  be  repeated. 

The  Results. — While  success  has  attended  the  operation  in  some  cases, 
the  outcome,  as  a  rule,  is  unfavorable. 

Suture  of  the  Patella  for  Fracture.— Suture  of  the  patella  with  wire  is 
now  generally  accepted  as  a  justifiable  measure  in  selected  cases.  In  our 
opinion,  the  operation  should  not  be  performed  except  for  other  reasons  than 
that  of  the  existence  of  a  simple  fracture  of  the  bone,  because  we  do  not 
believe  that  it  is  good  surgery  to  expose  a  patient  to  the  contingencies  of 
suppuration,  amputation,  anchylosis,  and  even  death,  for  the  better  rectifica- 


MlSC'KLIiAXKUUS   OPERATIONS. 


1201 


Fig.  1514.— Instruments  employed  in  repair  of  fractures  of  patella  and  long  bones. 

a.  Scalpels,  large  and  small,  b.  Forcipressure.  c.  Forceps,  thumb  and  mouse-tooth. 
(/.  liugine.  e.  Volkmann's  scoop.  /.  Brainard's  bone  drill,  g.  Hamilton's  bone 
drill,  h.  Fluhrer's  crocliet  drill.  /.  Silver-wire  suture,  j,  k.  Fluhrers  fork  and 
grooved  retractor.  L  Ciiisel.  m.  Toothless  iron-jaw  forceps,  n.  Periosteotome. 
0.  Phelps's  instrument  for  holding  fragments  of  patella,  p.  Saw.  q.  Retractors, 
hooked  and  blunt,  r.  Scissors,  straight  and  curved,  blunt-pointed,  s.  Rongeur. 
t.  Bone-cutting  forceps,  u.  Silver  wire.  v.  Curved  needle.  ?/'.  Ivory  pegs.  X. 
Spatula.  Silkworm  gut,  catgut,  silk,  sponges  and  wipers,  and  fine  curved  needles  are 
required. 


1262 


OPERATIVE   SURGERY. 


tiou  of  an  injury  which,  at  its  worst,  lias  no  tendency  to  terminate  fatally, 
and  almost  invariably  results  in  a  serviceable  limb  when  treated  by  the 
ordinary  methods.  It  is  as  impossible  as  it  would  be  unwise  to  indicate 
definitely  the  cases  for  wiring,  as  each  case  should  Ije  considered  on  its  own 
merits.  When  the  end  to  be  gained  will  justify  the  attempt,  the  operation 
need  not  be  deferred. 

Thorough  aseptic  measures  should  be  employed  in  connection  with  every 
essential  detail  of  the  procedure. 

Three  differe^it  incisions  are  practiced  in  this  operation :  the  vertical, 
the  transverse,  and  the  oval.  Tlie  vertical  incision  is  made  in  the  me- 
dian line  of  the  bone  down  upon  the  fracture,  and  is  of  sufficient  length 

to  permit  the  ready  exposure  of  the  line 
of  fracture  and  afford  room  to  cleanse  the 
joint.  In  this  instance,  one  or  two  wires 
— now  usually  one — is  employed,  and  is 
placed  at  the  median  line  in  front.  The 
writer  has  practiced 
this  form  of  incision 
frequently,  and  with 
entire  satisfac- 
tion. It  places 
the  scar  verti- 
cally, and  obviates  the 
danger  of  stretching 
or  rupture  when  over- 
flexion  happens.  The 
incision  does  not  af- 
ford as  favorable  an  opportunity  to  trim  and 
repair  the  lateral  laceration  of  the  capsule 
as  transverse  incision,  and  directly  invades 
the  prepatellar  bursa  (Figs.  378  and  1522). 
Tlte  transverse  incision  is  made  directly 
across  the  joint,  between  the  inner  and 
outer  aspects,  at  or  close  to  the  line  of 
fracture.  This  form  of  incision  permits  of 
extended  examination  of  the  joint  cavity  and  the  repair  of  lateral  laceration 
of  the  capsule.  However,  the  cicatrix  is  exposed  to  the  influence  of  direct 
and  to  flexion  violence,  and  in  many  instances  refracture  has  been  compli- 
cated with  laceration  of  the  cicatrix.  This  incision  is  almost  certain  to  open 
the  prepatellar  bursa  (Figs.  378  and  1521). 

The  oval  incision,  with  the  convexity  downward  or  upward  (Cheyne),  is 
a  good  form  of  incision.  It  affords  the  same  opportunities  as  the  trans- 
verse one,  but  with  less  danger  of  subsequent  complications.  It  extends 
between  the  outer  and  inner  aspects  of  the  knee  and  considerably  below 
or  above,  as  the  case  may  be,  of  the  line  of  fracture  in  front.  Lucas-Cliam- 
pionniere  is  an  earnest  advocate  of  the  flap  method.  It  should  not  involve 
the  prepatellar  bursa. 


Fig.  1515. — The  operation  of  suture 
of  patella,  Cheyne's  ov^al  iueision. 
Introduction  of  wire  through 
lower  fragment ;  leg  flexed. 


MISCKLLANKors   Ol'KltATIoXS. 


2<;;3 


The  Operation.— Vl-dcv  tlie  jnilient  on  the  buck  with  the  limb  extended 
and  tlie  heel  raised;  expose  the  fraeturc  freely,  and,  if  need  be,  the  joint 
cavity  through  the  selected  incision  ;  remove  blood  clots  from  the  broken 
aspect  of  the  fragments  with  a  bone  scooj),  and  intervening  fibrous  and 

other  tissue  with  scissors,  so  that  the 


fractured  surfaces  can  be  brought 
into  ])roper  apposition  ;  remove  from 
the  joint  cavity,  by  means  of  sponges 
and  hot  saline  solution  flushing,  blood 
clots  and  foreign  bodies,  giving  espe- 
cial atten- 
tion to  the 


upper  syno- 
vial pouch  (Fig.  378,  a),  and  to  the 
recognized  anatomical  recesses  of  the 
joint ;  if  drainage  is  to  be  intro- 
duced, carry  silkworm-gut  drainage 
into  the  joint  through  a  perforation 
of  the  tissues  made  at  the  lower  part 
of  the  external  condyle  from  within 
outward  by  means  of  a  long,  sharp- 
jiointed  scissors  curved  on  the  flat ; 
flex  the  leg  and  bore  each  fragment 
(Fig.  1515)  deeply  or  superficially  at 
one  or  two  situations  for  large  or 
small  wire,  as  circumstances  may  de- 
mand (Fig.  151G) ;  cleanse  the  joint  cavity  again,  and  bring  the  fractured 
borders  in  contact  with  each  other  by  twisting  the  ends  of  each  wire  together 
along  the  line  of   a   corresponding  incision  made  down  to  the  bone  by  a 


Fig.  1516. — The  operation  of  suture  of  pa- 
tella. Cheyne's  oval  incision.  Drilling 
lower  fragment ;  forceps  drawing  aside 
dividetl  fibrous  tissues  ;  leg  flexed. 


Fig.  1517. — The  operation  of  suture  of  patella,  Cheyne's  oval  incision.     Bringing  frag- 
ments together;  leg  extended. 

sharp-pointed  knife,  as  firmly  as  is  consistent  with  the  security  of  the  union 
(Fig.  1517) ;  cut  off  the  twisted  ends  a  quarter  of  an  inch  or  so  above  the 


1264  OPERATIVE   SURGERY. 

bone,  and  flatten  them  against  the  bone  (Figs.  1518  and  1527),  for  obvious 
reasons;  trim  the  torn  borders  of  the  capsule,  if  desirable,  and  close  the  gap 
with  an  interrupted  or  continuous  catgut  or  kangaroo-tendon  suture ;  unite 
the  divided  borders  of  the  patellar  fibrous  tissue  with  fine  catgut,  thus  shut- 
tinf^  off  the  more  completely  from  the  external  wound  the  joint  cavity;  close 
the  external  wound  with  interrupted  silkworm-gut  sutures  carried  deeply ; 
dress  the  wound,  and  confine  the  joint  immovably  in  an  extended  position 
until  repair  of  the  soft  parts  has  taken  place. 

The  After-treatment. — The  after-treatment  is  like  that  of  similar  wounds 
at  other  pai'ts  of  the  body.  When  the  healing  of  the  soft  parts  is  completed 
the  limb  may  be  encased  in  a  fenestrated  plaster-of- Paris  splint,  and  thus  the 
patient  may  be  around  on  crutches  until  bony  repair  is  established.  Usually 
patients  are  up  and  about  with  the  joint  controlled  by  a  plaster-of-Paris 
casement  or  only  by  a  jDOsterior  support  at  the  end  of  the  third  week. 
Phelpa  begins  early  to  move  the  patella,  thus  fitting  it  for  use  at  a  timely 
period.     Massage  is  an  essential  element  of  after-treatment. 

TJie  Precautions. — Thorough  asepsis  should  be  had  to  forestall  the  pos- 
sibility of  suppuration  of  the  joint  cavity.  Compound  fractures  of  the 
patella  should  be  wired  at  once,  simple  ones,  as  a  rule,  at  a  later  period — 
eight  or  ten  days  after  the  accident  (Phelps).  It  is  advised  by  some,  and  is 
justifiable  under  unfavorable  environment,  to  employ  the  douche  during  the 
operation.  In  case  suppuration  occurs  the  pus  should  be  liberated  at  once, 
the  joint  freely  washed  with  a  bichloride  solution,  rubber  drainage  tubes 
introduced,  and  continuous  irrigation  with  a  warm  bichloride  solution  (1  to 
10,000)  applied  until  the  suppuration  ceases  and  repair  begins.  If  pus  be 
present  in  the  superior  pouch  (Fig.  3T8,  a)  it  should  be  drained— and  better 
above — to  prevent  purulent  infiltration  of  the  tissues  of  the  thigh.  Too 
vigorous  or  too  early  passive  motion  may  cause  refracture  attended  even  with 
laceration  of  a  transverse  scar.  Observe,  in  wiping  the  joint  with  sponge  or 
gauze  (small  pads),  that  fragments  of  the  former  and  threads  from  the  latter 
do  )iot  remain  behind  to  cause  inflammation  ;  periarticular  suppuration  may 
happen  without  involvement  of  the  joint.  If  both  periarticular  and  articu- 
lar drainage  be  provided,  the  presence  of  pus  in  either  place  can  be  easily 
and  readily  detected,  and  evacuated  at  the  earliest  moment  without  the  dan- 
ger of  speculative  delay.  The  fragments  in  old  fractures  are  apt  to  be 
porous  and  friable  and  easily  torn  through  by  the  wire.  Drainage  should 
be  employed  or  not,  according  to  the  surgeon's  judgment  of  the  individual 
case.  He  should  strive  to  do  that  which  gives  to  the  patient  the  greatest 
security,  rather  than  that  which,  while  emphasizing  his  confidence  and  skill, 
may  unnecessarily  lessen  the  patient's  security — the  precept  being,  not  what 
one  can,  but  what  one  ought  to  do. 

The  Remarks. — In  the  writer's  judgment  the  articular  and  periarticular 
spaces  should  each  be  drained  independently  with  a  thread  or  two  of  silk- 
worm gut  in  all  instances  of  uncertainty.  The  measure  does  no  harm  and 
may  forestall  grave  disaster.  The  trimming  and  repairing  of  the  lacerated 
capsule  does  not  seem  necessary,  as  is  shown  by  the  uniformly  good  results 
— so  far  as  the  capsule  is  concerned — in  the  non-operative  and  subcutaneous 


M ISt'ELLA N K() L'S  U I'KK ATloNS. 


1205 


Fig.  1518. — The  operation 
of  suture  of  patella  for 
comminuted  fracture. 


mctliods  of  troatmont  (Figs.  15"il  and  l."»"-i4).  And  it  is  not  inqirohaljle  that 
the  rt'sulting  shortening  of  tiie  capsule  from  repair  adds  to  the  diflieuhy  of 
the  proper  attainment  of  post-operative  movement,  to  say  nothing  of  the 
greater  exposure  of  the  joint  to  infection  during  the  repair.  Disconnected 
fragments  of  bone  liable  to  necrose  should  be  removed.  When  the  bone  is 
broken  into  three  or  more  fragments,  a  sutticient 
number  of  sutures  should  be  employed  to  secure 
suitable  apposition  of  the  pieces  (Fig.  1518).  In  the 
instance  of  old  fracture  with  irreducible  separation, 
the  quadriceps  extensor  tissues  can  be  lengthened 
by  making  a  V-shaped  or  oblique  incision  (page  1269) 
through  them  sufficiently  to  permit  bony  apposition. 
The  wire  should  not  be  carried  through  the  under 
surface  of  the  patella  (Fig.  1519).  When  an  upper 
or  lower  fragment  is  very  small,  and  when  the  bone 
is  comminuted,  Lejiirs  surrounds  and  holds  in  place 
the  fragments  by  means  of  silver  wire  passed  through 
the  median  line  of  the  quadriceps  and  patellar  ten- 
dons and  close  to  the  borders  of  the  fragments,  so  as 

to  confine  them  in  proper  place  when  the  ligature  is  tightened.  Ceci  treats 
fractures  of  the  patella  in  a  similar  manner  with  silk  ligature  (page  1268). 
The  practice  of  exposing  the  fragments  by  means  of  a  vertical  or  transverse 
incision,  removing  the  blood  clots  and  uniting  the  fragments  with  kangaroo- 
tendon,  silk,  or  catgut  sutures  passed  through  the  margins  of  the  fibrous 
tissue  lying  on  the  patella,  the  same  as  in  fracture  of  the  olecranon  process 
(Fig.  1532),  is  favorably  considered  in  those  cases  with  but  little  tendency  to 
separation  of  fragments  or  the  occurrence  of  haemorrhage.  The  bony  bor- 
ders are  not  brought  as  closely  in  contact  by  this  plan  as  by  the  use  of  wire. 
The  facts  that  blood  clots  in  a  joint  are  thought  sometimes  to  form  mov- 
able bodies  there  and  are  known  to  be  admirable  culture  media  for  germs  in 

infected  cases,  emphasize  the  wis- 
dom of  their  removal.  At  the  end 
of  four  or  five  weeks  all  restraint 
is  removed,  and  passive  motion  of 
the  patella  from  side  to  side  and 
flexure  of  the  limb  are  begun,  and 
the  patient  is  encouraged  to  use 
the  joint,  which  usually  of  itself 
alone  will  restore  the  function  in 
a  few  weeks.  Douching,  friction, 
and  electricity  are  sometimes  ad- 
vantageous as  after-treatment  measures.  An  elastic  kneecap  may  be  worn 
for  a  time  as  a  reminder  of  infirmity,  if  for  no  other  reason. 

The  Results. — Prior  to  1883  the  patella  had  been  wired  49  times,  in 
which  2  of  the  patients  died,  1  of  pyaemia  and  1  of  exhaustion.  Besides 
these,  6  cases  resulted  in  suppuration  and  ankylosis.  Powers,  in  his  excel- 
lent  study  of  "operative  interference   in   recent  simple  fracture   of   the 


Fig.  1519. — Wire  introduced. 


1266  OPERATIVE  SURGERY. 

patella,"*  reported  711  cusos,  474  of  which  were  from  personal  communica- 
tions and  237  were  gathered  from  the  literature  of  the  two  years  2)receding 
the  presentation  of  the  paper.  Of  the  first  series,  4  died  ;  of  the  second,  6. 
Of  the  10,  3  died  from  sepsis  and  the  remainder  from  other  causes  not  related 
to  operative  technique.  Surely  the  difference  in  the  results  of  the  extremes 
(1883  and  1898)  exhibits  a  commendable  record  of  the  product  of  experi- 
ence. Powers  ascertained  the  opinions  of  67  prominent  surgeons,  living 
here  and  abroad,  regarding  the  advisability  or  non-advisability  of  operative 
interference  in  simple  fracture  of  the  patella.  Sevejiteen  were  "  opposed  to 
the  operation  in  any  case  " ;  nine  "  would  operate  in  all  cases  in  which  no 
distinct  contraindication  exists  and  in  which  the  surroundings  are  satis- 
factory " ;  forty-one  "  would  operate  in  selected  cases,  those  with  wide  dias- 
tasis, comminution,  etc."  More  pointedly  stated,  17  would  not  operate  on 
any  case  for  any  reason ;  9  would  operate  on  every  case  except  for  special 
reasons ;  41  would  operate  only  on  selected  cases  and  for  special  reasons. 

However,  the  perplexing  frequency  of  superficial  suppuration  and  rare 
occurrence  of  deep  suppuration,  of  ankylosis,  "poor  results,"  etc.,  to  say 
nothing  of  an  occasional  amputation  and  an  infrequent 
death,  still  emphasizes  the  need  of  wise  discrimination 
in  the  selection  of  and  greater  care  in  the  treatment 
of  cases  by  wiring,  and  also  by  other  methods  that 
involve  the  joint.  Xo  operative  plan  that  is  much  em- 
ployed is  without  the  history  of  an  unfortunate  out- 
come. 

Stimson's  Method  of  Treatment  {Silk  Suture)  (Fig. 
1520). — In  this  metliod  of  treatment  make  a  median 
longitudinal  incision  extending  well  above  and  below 
the  fragments,  down  to  the  bone  ;  remove  the  clots  from 
the  joint  cavity  and  from  the  fractured  borders  of  the 
bone;  lift  up  from  between  the  fragments  the  fibro- 
periosteal  fringe  that  may  be  there ;  pass  a  strong  silk 
Pi,;,  i.vjo.— The  opera-   suture    transversely    through    the  ligamentum  patellte, 

tion   of    suture    of  close  to  the  bone,  thence  in  the  opposite  direction  trans- 
patella,      Stinison  s  ,     , ,  ,    , ,  ,   .  ,       ,         ,        ^     -^    • 
Jngtho,l_                     versely  through  the  quadriceps  tendon  close  to  its  inser- 
tion by  means  of  a  strong  curved  needle  ;  hold  the  frag- 
ments in  apposition  and  tighten  and  tie  the  suture ;   close  the  cutaneous 
wound  without  drainage,  and  confine  the  limb  immovably  until  proper  repair 
has  taken  place. 

The  EestcUs. — "  This  method  seems  to  be  as  simple  as  any,  and  has 
proved  to  be  efficient  and  safe  in  more  than  fifty  personal  cases"  (Stimson). 
In  1896  Stimson  reported  75  cases  with  no  accidents  from  the  operation. 

Barker's  Method. — Barker's  method  is  quite  easy  of  performance  and 
can  be  accomplished  in  a  comparatively  short  time.  White  commends  this 
method  and  has  performed  it  fifteen  times  with  entire  success.  He  begins 
passive  motion  on  the  tenth  day,  gets  the  patient  out  of  bed  with  a  light 

*  Transactions  of  the  American  Surgical  Association,  1898. 


MlSCKI.I.AN'EOrS   OPEKAllnNS. 


12*;' 


Fig.  1521. — The  operation  of  ligature  of  patella,  Barker's 
method,  a.  Needle  passed  beneath  patella.  6,  c.  Wire 
ligature  in  eye  of  needle. 


splint  on  tlio  limb  jit  the  I'lul  of  tliu  third  woek,  aii-l  oxpoots  good  u.so  iu 

from  eiglit  to  ten  weeks. 

The  Operation. — Under  strict  antisepsis,  with  the  patient  on  the  back 

and  the  limb  e.xtended,  steaiiy  the  lower  fragment   with    the    thumb    and 

linger;  thrust  a  narrow-  ,. 

bladed    knife    with    the 

edge    upward,    through 

the  ligiimentum  patelhe 

at  the  point  of  insertion 

into  the  lower  fragment, 

into    the    joint  ;    carry 

through  the  wound  thus 

made  a   pedicle  needle 

(Fig.    1521),  passing   it 

upward      beneath      the 

fragments  through   the 

insertion  of  the  quadri- 
ceps at  the  base  of  the 

upper     fragment    sufli- 

ciently    to    elevate    the 

overlying     integument ; 

draw  the  integument  up- 
ward and  expose  the  end 

of  the  needle  through  a  short  incision  made  down  upon  it ;  push  the  end  of  the 

needle  through  the  opening,  and  thread  it  with  a  strong  sterilized  silk  thread 

or  silver  wire ;  withdraw  the  needle,  leaving  the  ligature  in  place ;  unthread 

and  pass  the  needle  through  the  same  primary  opening  upward  in  front  of 

the  fragments  and  out  of  the  upper  incision  (Fig.  1522) ;  rethread  the  needle 

with  the  ujiper  end  of  the 
cord  and  withdraw  the  nee- 
dle so  that  the  ends  of  the 
silk  will  both  present  at 
the  lower  incision  ;  approxi- 
mate the  fragments,  and 
displace  intervening  blood 
clots  and  other  material 
by  rubbing  them  together 
briskly  ;  tie  the  suture  tight- 
ly, cut  the  ends  short  and 
close  the  wound  (Fig.  1523). 
A  posterior  sj)]int  and  a 
figure-of-eight  bandage  are 

Fig.  1522.— The  operation  of  ligature  of  patella,  Bark-    then  applied.      Passive  mo- 
er's  method,     a.  Xeedle  passed  in  front  of  patella.    ,  •        •     ,  ^i      j.     j.i 

b.  c.  Wire  ligature  in  eye  of  needle.  tiO»  is  begun  on  the  tenth 

day  in  the  majority  of  cases. 

The  patient  may  be  up  and  around  with  a  plaster-of- Paris  dressing  in  three 

weeks. 

86 


1268 


OrKKATIVE   SURGERY, 


Tlie  IiesuUs. — Oood  use  of  the  joint  is  expected  in  two  montlis.  That 
this  phm  is  safer  than  the  freely  o])en  ones  there  can  be  no  reasonable  doubt. 
The  practical  outcome  cau  not  be  known  without  a  more  extended  expe- 
rience. 

Another  su3mttaneoiis  metJiod  (Ceci)  consists  in  surrounding  the  fractured 
bone  subcutaneously  with  a  buried   silk  ligature  in  quite  the  same  manner 

Lejars  employs  in  multiple  frac- 
<^2*  ture  of  the  patella,  and  in  frac- 

ture at  its  tendinous  insertions, 
passed  transversely  through  the 
ligamentum  patellae  at  its  inser- 
tion into  the  fragment,  and  so 
carried  around  the  bone,  pass- 
ing through  the  quadriceps  at- 
tachment (Fig.  152-4),  as  to 
draw  the  fragments  tightly  to- 
gether in  a  hoo])like  manner 
when  the  suture  is  tightened, 
and  tied  at  the  point  of  pri- 
mary puncture  (Fig.  1525).  The 
Fig.  1523.— The  operation  of  ligature  of  patella,  ordinary  curved  pedicle  needle 
Barker's    inetliod.      Twisting    wire    ligature;  ,     "  ,         i    x       i  xi 

bringing  fragments  together!  can  be    employed   to    draw  the 

suture  into  place.  Owing  to 
the  circular  shape  of  the  bone,  the  ligature  must  be  laid  in  segments,  the 
needle  being  reinserted  at  the  point  of  exit  in  each  instance  until  the  pri- 
mary puncture  is  reached,  when  the  suture  is  tied  as  just  described. 

TJie  Bemarls. — The  suture  should  be  carried  sufficiently  deep  at  the 
sides  to  penetrate  the  firm                 ,  ,, 
tissues     connected     with               |l(l'''f'l 
the  patella  at  those  situa- 
tions, in  order  to  properly 

control  the  fragments. 
In  comminuted  fracture 
tlie  plan  serves  to  unite 
the  fragments  closely. 
The  remaining  advantages 
claimed  for  the  method 
are  of  questionable  worth. 
Other  methods  of  arrange- 
ment of  the  suture  have 
been  suggested  and  occa- 
sionally practiced. 

In  old  fracture  of  the 
patella,     especially    with 
wide    separation    of    the 
fragments  causing  a  badly  cri})])led  limb,  union  of  the  broken  parts  in  some 
instances  requires  division  of  the  quadriceps  tendon,  and  even  the  rectus 


Fig.  1524.— The  operation  of 
subcutaneous  (wire)  liga- 
ture for  fracture  of  pa- 
tella, Ceci's  method. 


Fig.  1525.— The  ligature 
iiniteil  in  Ceci's  meth- 
od. Silver  wire  maybe 
used  instead  of  silk. 


iMiscKLi-ANi:()Ls  ()I'i:i;a'1'1(»ns. 


1269 


itself,  along  with  tiio  vusti  muscles,  ami  perliiips  tlieii  suitable  apposition 
<-an  not  be  secured  without  separation  by  mallet  and  chisel  of  the  tuberosity 
of  tlie  tibia  from  the  normal  site,  and  its  transplantation  and  fixation  at  u 
higher  j^oint  on  the  bone. 

'I'ltv  Anaioiniad  I'oinls. — The  lengtli  and  widlli  of  tiic  tendon  of  the 
quadriceps,  and  the  length  and  direction  of  the  lowermost  fibers  of  the  vasti 
in  health,  sliould  be  carefully  observed  1)efore  the  operation  is  commenced. 
These  lowermost  libers,  whicdi  are  markedly  concerned  in  maintaining  the 
patella  in  proper  relation  with  the  lower  end  of  the  femur,  may  have  become 
so  changed  in  their  structure  and  function  as  to  prevent  apposition  of  the 
bony  fragments  unless  they  are  freely  divided,  which  division,  however,  fjuite 
severs  the  musculo- 
tendinous Hap  and  iv^ji  ') 
the  attached  frag- 
ments of  the  patella 
from  nourishment 
until  after  wiring  of 
the  bone  and  suturing 
together  of  the  con- 
tiguous borders  of 
the  soft  parts  is  com- 
pleted, and  exposes 
to  serious  danger  of 
sloughing.  The  writ- 
er once  encountered 
this  obstacle  in  a 
marked  degree.  The 
relation  which  the 
site  of  operation  bears 
to  the  joint  cavity 
merits  careful  atten- 
tion (Fig.  378). 

The  varieties  of 
the  liberating  inci- 
sions employed  are 
usually  three  in  num- 
ber :  {(i)  the  triangu- 
lar; {b)  the  gable-sha))ed  ;  {c)  the  crenated  (Fig.  Ih-IQ>).  In  either  instance 
the  incisions  should  be  made  through  the  tissues,  and  after  their  elongation 
and  the  adjustment  of  the  bony  fragments  the  contiguous  borders  of  the 
former  are  sutured  together  (Fig.  lo'^'T).  The  longitudinal  incision  affords 
the  greatest  and  the  remaining  incisions  the  least  degree  of  elongation.  The 
greater  the  need  for  lengtliening,  the  higher  and  more  extended  the  oblique 
incisions  should  be  made. 

Tltc  Precautio7is. — Strict  asepsis  should  be  practiced.  The  incisions 
should  conform  strictly  to  the  needs  of  proper  joining  of  the  bony  frag- 
ments.    In  displacement  upward  and  implantation  of  the  tuberosity  of  the 


Fig.  1526. — The  operation  of 
eloiifjjition  of  the  quadriceps 
in  old  fracture  of  patella. 
(I.  Trianjiular  incision  with 
dotted  lilies  indicating  ex- 
Icnsion  of  incisions,  b.  Ga- 
l)lc-sha|ied  incision  (Keen). 
c.  Crenate  (Cheyne). 


Fio.  1527. — The  ends  in  cre- 
nate  incision  adjusted, 
united  together,  and  pa- 
tella repaired  (Cheyne).  In 
instances  a  and  h  (Fig. 
ir)2()).  elongation  followed 
liy  adjustment  and  sutur- 
ing of  contiguous  borders 
are  required. 


1270 


OJ'HliATlVE   SURGERY. 


tibia,  great  caution  is  necessary  not  to  seriously  impair  its  power  of  union 
with  the  now  point  of  attachment.  Since  septic  infection  may  invade 
and  ruin  the  exposed  joint  and  the  union  of  the  soft  and  hard  parts, 
destroying  their  respective  portions,  thereby  causing  defeat  of  operative 
purpose  and  possibly  loss  of  life,  it  is  evident  that  the  operation  should 
be  counseled  only  with  wise  discretion  and  performed  with  consninmate 
care. 

The  Results. — Keen,  Erdmann,  and  others  have  practiced  these  methods 
successfully.     Several  successful  cases  from  other  sources  are  reported. 

Rupture  of  the  Tendon  of  the  Quadriceps  Extensor  Femoris. — The  quad- 
riceps tendon  is  sometimes  ruptured  from  direct  and  indirect  violence. 
Rupture  may  be  mistaken  for  fracture 
of  the  patella,  and,  in  fact,  be  entirely 
overlooked. 

The  Operatio)is  for  Rupture.  —  In 
cases  where  ruptured  muscular  extrem- 
ities can  be  brought  together  they  may 
be  suitably  united  by  means  of  a  sup- 
porting thread  in  the  form  of  a  trans- 
verse loop,  passed  through  both  of  the 
ruptured    extremities,  supplemented  by 


Fig.  1528. — 1.  Method  of  suturing  divided  mus- 
cle. Four  sutures  placed  ready  for  tying  to 
the  bundles  of  muscle,  and  three  are  already 
tied  to  each  other.  2.  The  arrangement  of 
individual  sutures,  each  grasping  a  bundle 
of  fibers  (page  302). 


Pig.  1529. — Rupture  of  tendon  of  quadri- 
ceps extensor  femoris.  Uniting  rup- 
tured ends.  a.  Anterior  continuous 
adjustment  sutures,  b.  Posterior  con- 
tinuous adjustment  sutures,  c.  Bast- 
ing stitches.  (I.  Tendon  of  quadriceps. 


a  few  stitches  for  finer  adjustment  of  the  torn  edges  (Fig.  1528).  In  cases 
where  the  ruptured  ends  are  tendinous  (Fig.  1529),  pass  a  long,  heavy  silk 
thread,  by  basting  stitches,  transversely  through  the  two  ends,  about  half  an 
inch  from  their  edges ;  unite  by  a  continuous  suture  of  fine  silk  the  poste- 
rior margins  of  the  ruptured  ends.  Now  tie  the  transverse  suture,  and  then 
unite  the  anterior  margins  with  a  continuous  suture,  over  which  sew  the 
aponeurosis  and  skin.  In  cases  where  the  tendon  is  ruptured  close  to  its 
bony   insertion  pass   a   loop   of   silk   or  silver  wire   so   as   to   include   the 


MiSCKI.LANKors   OI'lllfA'I'lONS. 


1271 


iippiT  sci^tiu'ut  of  tlie  tdiii  tendon  iiliove  und  the  luitelUi  below  (I'ig. 
ir);JU).  ])rii\v  the  enils  of  (hi-  loop  taut,  thus  bringing  together  tlie  sepa- 
rated surfaces,  completing  the  apposition  by  a  continuous  suture  uniting 
the  a])posed  edges.  ]f  (he  ijap  be  Uw  hnuje  for  coujilal iaii  of  the  ri(2)lnred 
e/ids,  C/idi/i/iio/uiicre  recommends  suturing  at  a  distance  by  passing  a  loop 
of  silver  wire,  basted  in  and  out,  around   the  lower  >:- 

part  of  the  upper  segment  of  the  tendon,  not  far 
from  its  torn  margin.  This  acts  as  a  s|)lint  to  sup- 
port in  this  situation  tlie  two  Dr  three  longitudinal 
stitches  of  approximation  which  are  made  to  j)ass 
through  the  tendon  just  above  it.  lielow,  the  longi- 
tudinal stitches  pass  either  around  a  similar  trans- 
verse splint  stitch  ])laced  near  the  torn  margin  of  the 
lower  segment,  or,  if  the  latter  is  not  of  sufficient 
length,  through  the  i)atella  itself.  The  longitudinal 
stitches  are  likewise  of  silver.  Around  this  metallic 
structure,  in  young  subjects,  it  is  possible  that  the 
area  of  loss  of  substance  can  be  filled  in  by  the  devel- 
opment of  regenerative  fibrous  bundles. 

Tlie  Remarks. — If   the   bursa  lying   beneath  the 

tendon  (Fig.  878,  a)  has  been  ru])tured  it  should  be   ^^'f-  1530. --Rupture  of 

,  -      -,        '  .  |.      ,  .,  ,  tendon    of    quadnceps 

repaired,  and    due   cognizance  of    tiie   possible   out-       extensor  femoris.  Unii- 

come  on  the  knee  joint  from  this  cause  be  considered 

and  provided  for. 

llie  Results. —  Malker's  analysis  of  250  cases  shows 
tliat  72.5  per  cent  recovered  within  six  months  under 
mechanical  treatment,  also  that  80  per  cent  recov- 
ered completely  within  the  same  time  under  operative  treatment.  AA'alker 
states  that  operation  should  always  be  practiced  when  a  greater  sepaiation 
than  an  inch  and  a  half  is  present,  and  when  mechanical  measures  have 
failed. 

Suture  of  the  Olecranon  Process. — The  olecranon  process  is  sutured  for 
non-union  after  fracture  and  for  recent  fracture.  Under  strict  asepsis 
expose  the  seat  of  fracture  through  a  median  longitudinal  incision  ;  uncover 
the  fractured  surfaces  by  removing  intervening  tissue  or  blood  clots;  begin 
at  corresponding  points  of  sound  bone  about  a  quarter  of  an  inch  from  the 
border  of  either  fragment  and  drill  a  small  hole  obliquely  through  the  frac- 
tured surface ;  pass  through  the  openings  fine  silver  wire,  silk,  or  kangaroo 
tendon,  and  firmly  appose  the  fragments;  close  the  wound,  apply  the  dress- 
ings and  immobilize  the  joint  with  the  arm  completely  extended  (Fig.  1531). 
The  passage  of  kangaroo  tendon  or  silk  through  the  tendon  of  the  triceps 
near  to  its  point  of  insertion,  and  a  hole  made  transversely  through  the 
ulna  just  below  the  fracture,  is  an  admirable  method  of  suture.  In  either 
instance  the  torn  borders  of  the  fibrous  extension  overlying  the  olecranon 
should  be  sutured  together  with  catgut  (Fig.  1532).  In  case  the  tendon  is 
ruptured  it  is  repaired  in  the  same  manner  as  is  the  tendon  of  the  quadri- 
ceps extensor  muscle. 


ing  ruptured  end  of 
tendon  with  patella. 
a.  d.  Wire  sutures,  b. 
I^astinjj  stitches.  c. 
End  of  tendon,  e.  Pa- 
tella. 


1272 


OPERATIVE   SURGERY. 


Tlte  llemarks. — Suture  of  recent  fracture  of  the  olecranon  is  rarely 
advisable  except  when  the  separation  is  so  great  as  to  render  doubtful  the 
serviceability  of  the  limb.    In  cases  of  crippling  from  non-union,  tlie  method 


Fiu.  1581. — The  operation  of  suture  of  olec- 
ranon process,  a,  b.  Wire  sutures.  c. 
Tendon  of  triceps  muscle,  d.  Broken 
surface  of  upper  fragment  of  olecranon, 
e.  Trochlear  surface  of  humerus.  /.  Bone 
drill,  g.  Lower  portion  of  olecranon 
process,     h.  Periosteum. 


Fig.  1532. — The  operation  of  suture  of  olec- 
ranon, a.  Continuous  suture  uniting- 
torn  periosteum,  b.  Tendon  of  triceps. 
c.  Upper  fragment  of  olecranon,  d. 
Lower  portion  of  olecranon,  e.  Wire 
suture  in  place,  ends  twisted  and  tui'ned 
down.    /.  Periosteum. 


finds  its  greatest  use.  Passive  motion  should  be  commenced  early  and  em- 
ployed with  caution.  The  suture  should  not  be  j^assed  in  contact  with  the 
articular  surface. 

The  Union  of  Fractured  Long  Bones. — The  fractured  ends  of  a  long  bone 
sometimes  persistently  override  each  other  in  spite  of  the  efforts  to  reduce 
and  retain  them  in  place,  causing  serious  deformity,  protracted  and  incom- 
plete recoverv,  and  perhaps  exposing  to  injury  important  contiguous  struc- 


Fi(..  IV;.;.  -Suture  of  trans- 
verse fracture  with  one  su- 
ture. Another  may  be  in- 
troduced at  opposite  side. 


Fig.  1534.  —  Suture  of 
transverse  fracture  with 
a  single  suture. 


Fig.  1535. — Suture  of  oblique 
fractui-e  with  single  suture. 
An  insecure  method. 


tures.  Both  simple  and  compound  fractures  are  often  liable  to  these  objec- 
tions. It  is  proper,  however,  to  state  that  attempts  at  relief  by  the  following 
methods  of  treatment  are  now  less  frequently  practiced  than  formerly,  and 


.MISCKLLANKUL'S    Ul'KUATIONS. 


1273 


Fig.  1536. — Ligature  of  oblique  fracture  by  peripheral 
inelliod.     Not  the  most  secure. 


Fig.  1537. — Oblique  lifr.it  uitMi'  ..lilique  fracture,  periph- 
eral method.     The  most  secure. 


tliiit  tlu'ir  utilization  is  not  wise  unless  prompted  by  considerations  of  more 
than  usual  interest  to  the  welfare  of  the  patient.  Three  iiicllioda  of  nniliny 
the  fra<,Mnents  are  employed  :   1,  liy  suture;  2,  by  ligature  ;  3,  by  j)eg<^in<,'. 

In  suture  of  bo)ii\  i.''\\\wv  silver  or  ])latinurn  wire  or  heavy  silk  nuiy  be 
em])loyed. 

In  tnoisverse  fracture,  {)erforate  the  bone  perpendicularly  to  the  surface 
and  employ  either  two  sutures,  one  at  either  side  (J'^iir.  i.")3.'}),  or  a  single 
suture  passing  transversely  ^—  - 


through      both     fragments 
(Fig.  ir.34). 

In  oblique  fracture,  drill 
the  fragments  so  that  the 
suture  will  be  at  right  an- 
gles to  the  line  of  fracture, 
otherwise  the  movement  is 
not  controlled  (Fig.  1535). 
The  ends  of  the  wire  suture 
are  twisted,  the  excess  cut 
off,  and  the  remainder  ham- 
mered against  the  bone. 

Ligature  of  bu>n'  is  em- 
ployed in  cases  of  exceed- 
ingly oblique  ajid  commi- 
nuted fractures.  In  this 
method  simple  peripheral 
ligature  and  ligature  com- 
bined with  suture  are  em- 
ployed. 

The  former  procedure, 
while  not  the  most  secure, 
is  often  serviceable.  The 
ligature  can  be  carried  around  the  bone  at  the  point  of  the  greatest  tendency 
to  separation,  either  at  right  angles  with  the  long  axis  of  the  bone  (Fig.  1536) 
or  with  the  direction  of  the  fracture  (Fig.  1537).     In  either  instance  the  bone 

should  be  notched  at  the  seat  of  application,  to 
hold  the  ligature  firmly  in  place,  and  supple- 
mentary suture  may  be  made  when  needed. 
Two  circular  ligatures  passed  around  the  seat 
of  fracture  and  united  together  with  two  lon- 
gitudinal loops  may  be  employed  (Fig.  1538). 
Combined  ligature  and  suture  (Fig.  1539)  is 
performed  by  drilling  perpendicularly  to  the  line 
of  the  fracture,  through  which  opening  a  loop 
of  wire  is  passed.  The  threads  are  crossed  within  the  bone,  then  caused 
to  encircle  the  bone  snugly  one  at  either  side,  and  the  protruding  ends 
are  passed  through  the  loop  and  fastened.     An  accessory  ligature  may  be 


Fig.  1538. — Double  circular  ligature  of  oblique  frac- 
ture, with  two  longitudinal  loops.  Ligatures 
should  surround  seat  of  fracture. 


Fig.  1539. — Combined  ligature 
and  suture  of  oblique  frac- 
ture. 


employed  if  the  fracture  be  very  oblique. 


1274 


OPERATIVE  SUEGERY. 


Fig.  1540. — Frame  ligature  of  oblique  fracture, 
first  step. 


The  frame  ligature  lorovides  the  greatest  degree  of  immobility.  Drill 
two  holes  through  the  extremities  at  a  right  angle  to  the  long  axis  of  the 
bone  (Fig.  1540),  and  jiass  the  ends  of  a  looped  wire  through  them;  draw 
the  loop  over  the  ends  at  the  opposite  side  of  the  bone  (Fig.  1541) ;  draw 
the  ends  tight,  carry  them  around  the  shaft  of  tlie  bone  to  the  openings, 

pass  tliem  beneath  the  re- 
spective wires,  bring  them 
together,  and  twist  firmly 
in  place  (Fig.  1542). 

Tliepegyuig  of  fractures 
by  peri2)heral  and  intra- 
medullary introduction  of 
pegs  of  ivory  or  of  decalci- 
fied and  of  fresh  bone  is  not 
infrequently  practiced.  In 
oblique  (Fig.  1543)  and 
multiple  (Fig.  1544)  frac- 
tures, union  by  drilling  and 
pegging  together  of  the 
fragments  is  often  a  com- 
mendable procedure,  better, 
in  fact,  than  wiring. 

Intramedullary  pegging 
is  practiced  in  the  conti- 
nuity of  long  bones  (Fig. 
1545)  as  follows  :  Make  the 
site  of  the  fracture  gape  by 
lateral  flexion  ;  drive  the 
peg  into  the  lower  fragment 
with  light  strokes  as  far  as 
suitable ;  grasp  the  lower 
fragment,  bend  it  strongly 
laterally  and  downward  un- 
til the  free  extremity  of  the 
peg  can  be  introduced  into 
the  medullary  cavity  of  the 
ujiper  fragment,  when  the 
two  are  driven  together. 
The  periosteum  is  then  su- 


FiG.  1541. — Frame  ligature  of  oblique  fracture, 
second  step. 


Pig.  1543. — Frame  ligature  of  oblique  fracture, 
operation  completed. 


tured  in   i^lace    (Fig.  1546),   the   limb  dressed  aseptically  and  fixed   by  a 
plaster-of- Paris  dressing. 

In  instances  of  loss  of  bone  structure  in  which  the  i^eriosteum  cor- 
responding to  the  intermediary  space  is  intact,  a  peg  may  be  introduced  into 
the  respective  medullary  openings  of  the  upper  and  lower  fragments,  thus 
retaining  them  in  their  proper  relation.  The  periosteum  is  then  sewed 
around  the  peg  and  the  limb  dressed  as  before  (Fig.  1547).  In  the  young 
successful  outcomes  from  this  plan  of  practice  are  reported. 


•MlSCKI.I.ANKors    ()|');UA'I'I(»NS. 


12 


(O 


Tlic  liemarJcs. — Stiict  lusi-psis  iiiiisL  bo  i)nietict'(l  iuid  iniiiiobility  secured 
if  successful  results  jirc  expected.     Fragiueiits  of  bono  not  i)ro2)erly  vitalized, 


Fio.  1543. — rcfjffing  single  oblique  fracture, 
|)eriplieriil  nietliod.  r/,  b.  Soft  parts,  c. 
Pegs.     (/.  Line  of  fracture. 


Fig.  1544. — Pegging  multiple  fracture, 
pei'ijiheral  method,  a,  b.  Vertical 
and  transverse  pegs. 


because 
repair. 

/ 


of  crushing  or  of  loss  of  ])eriosteum,  offer  but  little  chance  of  proper 
The  form  of  suture  or  ligature  should  be  employed  that  best  meets 

the  indication  without  causing 
undue  disturbance  of  the  soft 
parts  and  the  fragments  during 
its  application.     Pegging  of  long 


Fig.  1545. — Pegging  fracture  of  long  bone, 
intramednllarv  method.  ((.  Periosteum 
of  upper  fragment,  h.  Pin  with  one 
end  introduced,  c.  Periosteum  of  lower 
fragment.      d,  e.  Soft  parts. 


Fig.  1546. — Closing  periosteum  over 
pegged  fracture  of  long  bone  by  in- 
tramedullary method.  a,  b.  Soft 
jiarts.  c.  Outline  of  pin.  d,  e.  Sew- 
ing of  borders  of  periosteum. 


bones  by  the  peripheral  plan  usually  is  better  than  union  by  suture  or  liga- 
ture.    Ivory  pegs  are  the  easiest  of  introduction  and  of  application.     Decal- 


1276 


OPEIIATIVE  SUKGEliY. 


cified  bone  is  soft  and  suited  only  for  certain  cases.  Fresli  bone  is  excel- 
lent, but  difficult  to  prepare.  The  pegs  should  snugly  fit  the  openings,  and 
be  cut  off  so  as  to  be  readily  covered  with  the  periosteum.     ^Medullary  pegs 

should  fit  closely,  and  be  introduced  far 
enough  to  obviate  lateral  deviation — an 
inch  to  an  inch  and  a  half  will  suffice. 
However,  the  upper  end  of  the  peg  can 
not  be  caused  to  penetrate  the  corre- 
sponding fragment  as  far  as  the  lower. 

ParJihill  has  secured  commendable 
results  from  fixation  of  the  fragments  by 
a  special  apparatus  devised  by  himself. 
The  ends  of  the  fragments  are  suitably 
adjusted  by  means  of  resection,  the  use 
of  the  rongeur  and  Yolkmann's  spoon. 
"  Each  fragment  is  drilled  transversely 
to  the  longitudinal  axis  of  the  bone  in 
two  places.  A  small  steel  pin  is  thrust 
into  the  first  hole  while  the  second  is 
being  drilled,  in  order  that  they  may  be 
made  parallel.  The  distance  that  these 
pins  should  be  from  each  other  and  from 
the  ends  of  the  bones,  should  be  deter- 

FiG.  1547. — Intramedullary  pegging   of  mined  by  the  bone  under  operation  and 

fracture  of  long  bone,  with  loss  of  sub-  .      ^j        •       ^  ^j        j  ^    ^  ^      rpj 

stance,  periosteum  being  sewed  around  J  _  ^  _ 

peg^   rt,  h.  Soft  parts,     c.  Periosteum,  screws  are  introduced  into  these    holes 

by  means  of  a  clock  key,  and  the  wings 

are  adjusted.    While  the  bones  are  held 

in  accurate  apposition,  the  halves  of  the  instrument  are  clamped  together  " 

(Fig.  15-48).     The  soft  parts  are  then  accurately  adjusted  around  the  screws 

(Fig.  1549),  and  the  dressing  is  applied,  leaving  the  clamp  outside.     The 

apparatus  is  removed  in  from  four  to  six  weeks,  depending  on  the  size  of 


Peg.       e.   Periosteum 
/.  Outline  of  peg. 


sewed   over 


Fiu.  1548. — Fixation  of  fra^riueiils  in  fracture  of  Ion 


mctliud. 


the  bone.  The  writer  having  had  no  experience  in  the  use  of  this  appli- 
ance, leaves  its  employment  to  the  judgment  of  the  profession.  Parkhill's 
experience  justifies  a  belief  in  its  utility  in  suitable  cases. 

Nailing  the  Head  of  the  Femur. — There  are  two  conditions  for  the  relief 
of  which  this  procedure  has  been  employed  :  first,  for  recent  fractures,  when 


MIS("ELLANE()rS   OPKKATIONS. 


1277 


some  coexisting  condition,  such  as  the  age  of  the  patient  or  tlie  existence  of 
some  deformity,  renders  it  inexpedient  to  subject  the  sufferer  to  prohjnged 
mechanical  treatment  witii  the  attendant  risks  of  non-union  and  exhaustion; 
and,  second,  in  cases  of  nnunited  fracture  of  the  neck  of  the  femur.  Treat- 
ment by  Buck's  extension,  until  so  far  as  possible  the  normal  length  is 
restored,  should  precede  all  operative  attempts. 

The  operative  treatment  in  these  cases  was  first  suggested 
by  Langenbeck,  and  successfully  carried  out  by  Koenig. 


Fig.  1549. — Fixation  cif  fragincnts  in   fracture  of  long  bone.   Parkhill's  method.      Soft 

parts  adjusted. 

Koenig  operated  in  a  case  of  recent  fracture,  making  a  small  incision 
over  the  outer  side  of  the  trochanter  major,  drilled  a  hole  through  it  with  a 
metal  drill  in  the  direction  of  the  head  of  the  bone,  applied  extension  to  the 
limb  to  the  extent  necessary  to  overcome  the  deformity,  and  then  drove  a 
long  steel  nail  through  the  canal  in  the  trochanter  into  the  head  of  the  bone 
and  left  it  there.     The  limb  was  then  immobilized  and  extended  for  six 


Kui.  lo.JU. — Fixation  of  frasrnients  ui  fracture  of  neck  of  femur,  l*arkiiiirs  inetiiod 


weeks.     There  is  no  record  of  the  ultimate  shortening,  but  good  union  and 
free  motion  of  the  joint  were  obtained. 

Cheyne,  in  a  case  of  recent  fracture,  exposed  the  fragments  through  a 
longitudinal  iucision  made  over  the  anterior  aspect  of  the  joint,  exposed  the 


1278  OPERATIVE  SURGERY. 

fracture,  made  extension  and  internal  rotation  on  the  limb,  and  with  the 
fingers  in  the  wound  manipulated  the  fragments  into  place ;  then  a  small 
longitudinal  incision  was  made  over  the  outer  side  of  the  trochanter  major, 
and  two  canals  drilled  through  the  fragments  at  a  distance  of  half  an  inch 
apart.  Ivory  pegs  were  then  driven  through  the  holes  made  by  the  drill, 
and  the  limb  immobilized.  Good  union  and  motion  were  obtained,  but 
there  is  no  record  of  measurements  of  the  limb. 

In  operating  upon  cases  of  ununited  fracture  the  refreshing  of  the  ends 
of  the  fragments  is  a  necessary  step  in  the  technique. 

Meyer\  in  a  case  of  ununited  fracture  with  three  inches  shortening, 
made  the  Langenbeck  incision  for  excision  of  the  hip  joint  (Fig.  393), 
exposed  the  seat  of  fracture,  scraped  the  ends  of  the  fragments  until 
they  bled,  reduced  the  deformity  by  extension  of  the  limb,  and  fastened 
them  together  by  driving  two  nails  through  the  trochanter  major.  A 
useful  joint  was  obtained,  with  an  inch  and  a  half  shortening  of  the  limb. 
Parkliill  commends  this  method  for  fracture  of  the  neck  of  the  femur  (Fig. 
1550). 

Gillette  reports  three  cases  of  ununited  fracture  of  the  neck  of  the  femur 
operated  upon  of  the  following  manner : 

A  horseshoe  incision  with  its  convexity  downward  was  made,  beginning 
an  inch  below  and  an  inch  posterior  to  the  anterior  superior  spine  of  the 
ilium,  carrying  it  down  two  inches  below  the  trochanter  major  and  bringing 
it  up  the  buttocks  to  about  the  center  of  the  gluteus  maximus  muscle.  The 
skin  and  the  two  layers  of  fascia  were  dissected  up  en  masse.  A  chain  saw 
was  then  passed  between  the  posterior  border  of  the  tensor  vaginse  femoris 
and  the  gluteus  medius,  hugging  the  neck  of  the  femur  and  the  base  of  the 
trochanter  major;  it  was  brought  out  between  the  posterior  surface  of  the 
gluteus  medius  and  the  anterior  surface  of  the  gluteus  maximus ;  the  tro- 
chanter major  and  its  muscular  attachments  were  sawed  off,  turned  back, 
thus  exposing  the  capsule  of  the  joint.  Then,  by  making  a  longitudinal 
incision  into  the  capsule  the  fracture  could  be  easily  seen.  The  surfaces  of 
the  fractured  ends  were  denuded  and  a  bone  peg  driven  through  the  neck 
of  the  femuF,  thus  holding  the  fractured  ends  together.  The  capsule  was 
stitched  with  catgut,  the  trochanter  major  restored  and  nailed  in  place  with 
a  small  bone  peg,  the  skin  closed,  and  the  limb  immobilized. 

There  was  union  and  good  motion  obtained  in  all  the  cases,  with  short- 
ening of  from  an  inch  to  an  inch  and  a  half. 

Curtis,  in  a  case  of  ununited  fracture  of  the  neck  of  the  femur  of  three 
months'  standing,  exposed  the  fracture  through  an  anterior  incision,  passed  a 
drill  into  the  callus  and  between  the  fragments  to  cause  irritation,  applied 
extension  to  the  limb  and  reduced  the  deformity,  after  which  a  drill  was 
passed  through  the  trochanter  major  from  the  outer  side,  transfixing  the 
fragments;  the  handle  of  the  drill  was  then  removed  and  the  drill  itself  left 
in  situ.  The  anterior  wound  was  closed  and  the  limb  immobilized.  The 
extension  was  maintained  for  six  weeks,  at  the  end  of  which  time  the  drill 
could  be  easily  removed.  Good  union  and  a  useful  limb  were  obtained  with 
three  quarters  of  an  inch  shortening. 


lAllSCKI.IiA.NKoLS    UL'KCA'llUNS.  1271) 

'J'liore  is  yet  n  rojisoiiiiblc  doiiht  ro^ardiug  the  a(lvisiil)ility  of  this  opera- 
tion except  in  special  cases.  The  dilliciilty  of  securing'  and  maintaining 
jn-oper  adjustment  of  the  fragments  because  of  the  hick  of  command  of  the 
inner  portion,  its  porous  character  and  low  vitality,  present  obstacles  to  suc- 
cess that  can  not  be  gainsaid.  The  degree  of  shortening  that  follows  tlie 
successful  results  suggests  an  initial  failure  of  reduction  of  the  deformity 
or  tiie  maintciKince  in  proper  place,  and  bespeaks  in  any  event  a  consider- 
able amount  of  absorption  at  the  seat  of  the  fracture.  A  more  extended 
expei'ienco  is  needed  and  a  careful  comparison  of  the  favorable  results  by 
dilTcrent  methods  of  treatment  is  required  before  a  linal  judgment  can  be 
recorded. 

Movable  Bodies  in  Joints, — Movable  bodies  in  joints,  joint  derangement, 
defective  semilunar  cartilages,  and  synovial  folds  are  conditions  (piite  often 
confused  with  each  other,  and,  in  fact,  are  seldom  positively  distinguishable 
without  a  physical  demonstration.  If  a  movable  body  appear  beneath  the 
surface,  the  patient  should  remain  as  quiet  as  possible  pending  the  arrival 
of  the  surgeon,  who  shonld  then  transfix  it  at  once  with  a  sharp  needle,  if 
feasible,  to  prevent  its  esca])e  into  the  recesses  of  the  joint  while  prepara- 
tion is  being  made  for  its  removal.  Strict  asepsis  should  be  enjoined  in 
every  respect.  Either  an  oval  incision,  including  the  site  of  the  movable 
body,  or  one  made  directly  npon  it,  may  be  employed.  The  tissues  are 
divided  carefully  down  upon  the  object,  and  it  is  then  removed  if  discon- 
nected, and  clipped  oft'  with  scissors  if  connected,  as  it  sometimes  is,  to  the 
semilunar  cartilage  or  synovial  fold.  The  synovial  incision  is  carefully  and 
independently  closed  with  a  continuous  suture  of  fine  chroniicized  catgut. 
The  incision  in  the  fibrous  capsule  should  be  treated  in  a  similar  manner. 
The  remaining  portion  of  the  wound  is  closed  with  interrupted  silkworm- 
gut  sutures.  If  it  should  appear  that  the  trouble  is  dependent  on  derange- 
ment of  a  semilunar  cartilage,  and  the  obstinacy  of  the  affliction  forbids  the 
expectation  of  other  than  operative  relief,  a  transverse  or  a  broad-based  oval 
incision  with  the  base  upward  should  be  made  over  the  seat  of  the  cartilage 
in  question.  The  joint  is  carefully  opened,  the  cartilage  exposed  to  view, 
and  its  movements  carefully  noted  as  the  leg  is  flexed  and  extended.  If  it 
be  too  freely  movable  because  of  a  stretched  or  ruptured  coronary  ligament, 
thereby  permitting  it  to  be  caught  between  the  advancing  articular  surfaces, 
the  ligament  should  be  shortened  and  sewed  with  chroniicized  catgut  to  the 
periosteum  at  the  border  of  the  tibia.  If  the  ligament  has  been  torn 
away  from  its  fastening  to  the  tibia,  it  should  be  restored  in  place  and  fas- 
tened the  same  as  before,  by  sewing.  If  it  be  roughened  or  deformed  so  as 
not  to  operate  without  a  hitch,  its  movements  should  bo  restricted  as  much 
as  possible  by  sewing  in  the  manner  already  stated.  If  it  be  doubled  upon 
itself,  or  so  much  deformed  as  to  unfit  it  for  use,  it  should  be  removed  at 
once. 

The  Precaniions. — Strict  asepsis  should  be  applied  throughout  the  opera- 
tion. Antiseptic  solutions  ought  not  to  be  permitted  in  contact  with  the 
exposed  surfaces,  especially  those  of  the  joint  cavity  itself.  The  explora- 
tion of  the  joint  cavity  through  a  free  incision  for  the  purposes  of  diagnosis 


1-2>>V 


OPERATIVE   .sUKGEKY 


and  possible  removal  of  the  oflfeuding  cause  should  not  be  attempted  unless 
it  shall  appear  that  the  burden  of  the  infliction  and  of  its  consequent  effects 
on  the  joint  are  of  equal  significance  to  those  arising  from  explorative 
j)ractice. 

The  Remarks. — The  cartilages  are  normally  movable  because  of  the  need 
of  their  action  to  facilitate  the  functions  of  the  joint.  The  diagonal  divi- 
sion into  two  parts  of  a  too  freely  movable  cartilage,  and  the  stitching  of 
each  independently  to  the  periosteum  at  the  border  of  the  tibia,  is  com- 
mended by  some  operators.  The  divided  borders  of  the  respective  tissues 
of  the  wound  are  united  the  same  as  in  the  j^receding  instance.  Drainage 
need  not  be  made  unless  faulty  technique  is  suspected.  Operative  practice 
is  not  advised  until  after  other  and  simpler  means  of  relief  have  failed, 
except  when  a  movable  body  presents  itself  beneath  the  surface,  and  then, 
should  it  escape  into  the  joint,  it  is  better  to  await  a  reappearance  than  to 
open  the  joint  and  seek  for  it  at  once.  Transverse  incisions  weaken  the 
joint  more  than  the  vertical. 

The  Besults. — The  following  statistics  will  emphasize  the  outcome  of 
operative  practice  more  pointedly  than  words  alone  can  do.  Also  the  com- 
parative importance  of  aseptic  measures  and  perfected  technique  are  strik- 
ingly shown : 


Xumber  of 
ca-ses. 

Cured 
■per  cent. 

Failures 
per  cent. 

Mortality 
per  cent. 

Bearadorf 

Lorry  (1860) 

Browne  (1884)     

216 
167 

88 
107 

66.2 

68.86 
82.95 
97.19 

18.99 

19.76 

5.68 

2.81 

14.81 
11.38 
12.36 

Tuttle 

The  Frontal  Sinus. — It  is  sometimes  necessary  to  open  the  frontal  sinus 
to  liberate  intlammatory  products  and  remove  foreign  bodies,  etc. 

The  Anatomical  Points. — The  frontal  sinuses  are  spaces  developed  at 
either  side  by  separation  of  the  tables  of  the  skull  at  that  situation.  The 
development  begins  at  about  two  years  of  age  and  continues  usually  during 
life,  so  that  the  sinuses  are  therefore  largest  in  old  age.  They  vary  in 
capacity,  sometimes  being  an  inch  in  depth,  and  may  extend  halfway  up  the 
forehead.  They  are  commonly  separated  in  the  median  line  from  each 
other  by  a  bony  septum,  are  lined  with  mucous  membrane,  and  communi- 
cate freely  with  the  nasal  cavity  through  the  infundibuluni. 

Tlie  Operation  of  Opening  a  Frontal  Sinus. — Shave  and  cleanse  the 
supraorbital  area  thoroughly,  administer  an  anaesthetic,  and  place  the  patient 
on  the  back  with  the  shoulders  raised  and  the  head  extended;  make  an 
incision  from  the  center  of  the  supraorbital  ridge  inward  along  the  upper 
border  of  the  eyebrow  to  the  median  line  above  the  root  of  the  nose;  raise 
and  push  aside  the  periosteum,  and  with  a  chisel  or  mallet  make  a  small 
opening  through  the  anterior  wall  of  the  cavity  (Fig.  2';T)  ;  cleanse  the  sinus 
thoroughly  and  remove  the  diseased  products.  The  wound  of  the  soft  parts 
should  be  closed  at  once,  except  at  the  inner  angle,  which  is  left-  open  for 
drainage  purposes.     If  the  infundibuluni  be  patent  the  external  wound  may 


MlSCKl.LANKoUS   Ul'KKATIUNS. 


1281 


Fig.  Io.jI. 


-Draining  frontal  sinus  into 
j)hiirynx. 


be  entirely  closed  at  once.  It  is  bettor,  bowever,  to  introduce  a  .'trand  or 
two  of  silkworm  gut  tlirougb  the  canal  into  the  nasal  cavity,  leaving  the 
upper  ends  exposed  at  the  angle  of 
the  wouiul  for  two  or  three  days 
before  removal,  than  to  rely  at  once 
on  the  uncertainties  of  the  nuiinte- 
nance  of  drainage  along  narrow  chan- 
nels lined  with  mucous  membrane 
with  tickle  characteristics.  When 
extensive  disease  is  present  requiring 
much  time  for  cure,  it  is  wise  to  drain 
through  into  the  nose  or  pharynx 
with  a  tube  of  considerable  size  (Fig. 
1551). 

The  Comments. — All  that  is  prac- 
ticable should  be  done  to  prevent 
scarring  and  infiltration  of  the  loose 
tissues  about  the  orbit.  The  eyes 
should  be  carefully  protected  from 
the  discharges  and  from  the  anti- 
septic liuids  employed  in  the  treatment.  The  infundibulum  runs  down- 
ward and  backward  for  a  short  distance,  tlien  turns  shar])ly  forward  and 
downward,  and  enters  the  uasal  cavity — facts  that  should  be  remembered 
in  probing  tlie  canal. 

The  Maxillary  Sinus. — The  maxillary  sinus  or  the  antrum  of  Highmore 
is  of  great  importance  in  connection  with  facial  disfigurement  and  functional 
impediment,  due  to  encroachment  on  the  orbital  and  nasal  fossae  of  the  mor- 
bid products  arising  from  disease  of  the  antrum. 

The  Anatomical  Points. — The  antrtim  of  the  adult  is  a  triangular-shaped 
cavity  of  considerable  size,  bounded  above  by  the  orbital  floor,  below  by  the 
alveolar  process,  within  by  the  wall  of  the  nasal  fossa,  and  without  by  the 
malar  process  of  the  maxilla.  It  is  lined  wutli  mucous  membrane  and  com- 
municates with  the  middle  meatus  of  the  nasal  fossa  by  a  small  opening.  The 
relation  of  the  floor  of  the  antrum  to  the  roots  of  the  teeth  varies  widely;  it 
may  extend  so  as  to  correspond  to  the  roots  of  nearly  all  the  teeth  of  the 
true  maxilla,  or  may  be  so  contracted  as  to  bear  a  definite  relation  with  only 
one  or  two  of  the  posterior  molars.  Occasionally  the  roots  of  one  or  more 
of  the  posterior  molar  teeth  project  into  the  floor  of  the  antrum,  incased, 
however,  normally  by  a  thin  plate  of  bone  covered  with  mucous  membrane. 

The  Operation  of  Opening  the  Maxillary  Sinns. — The  antrum  is  opened 
through  the  socket  of  a  molar  tooth,  or  through  the  facial  surface  of  the 
maxilla,  at  a  point  corresponding  to  the  root  of  the  second  or  third  molar 
tooth.  In  the  former  instance  the  second  or  third  molar  tooth  is  extracted 
and  the  socket  is  perforated  above  by  means  of  a  bone  drill  carried  carefully 
upward  through  the  floor  of  the  cavity.  If  the  tooth  in  question  be  diseased, 
the  removal  only  may  suffice  to  secure  an  opening.  In  either  instance  the 
opening  should  be  enlarged  sufficiently  by  the  introduction  of  a  larger  drill 


1282  OPERATIVE  SURGERY. 

to  permit  of  a  free  discharge  and  cleansing  of  the  cavity.  When  the  avail- 
able teeth  of  the  afflicted  side  have  been  long  removed  and  atrophy  of  their 
former  sites  has  taken  place,  the  opening  is  then  made  at  a  point  on  the  an- 
terior surface  of  the  bone  corresponding  to  the  former  location  of  the  second 
or  third  molar  tooth.  The  cheek  is  drawn  aside  and  the  lip  turned  upward, 
followed  by  an  incision  of  the  mucous  membrane  and  periosteum  over  the 
selected  site.  The  soft  parts  are  drawn  aside,  the  bone  exposed  and  perfo- 
rated in  an  upward  direction  by  means  of  a  small  trephine,  or  a  large  trocar, 
or  bone  drill,  or  strong  scissors. 

The  Preccmtions. — It  is  wise  to  first  remove  the  diseased  tooth  that  com- 
plicates the  antrum  involvement,  as  it  only  may  be  the  exciting  cause  of  the 
trouble.  The  perforating  agent  should  be  introduced  with  care  and  proper 
restraint,  or  it  may  perforate  the  floor  of  the  orbit.  A  careful  examination 
of  the  diseased  products  should  be  made  at  once,  to  determine  the  nature  of 
the  disease.  If  a  scoop  be  used  to  remove  the  diseased  tissue,  care  should  be 
taken  not  to  needlessly  expose  healthy  bone,  as  necrosis  will  quite  surely  fol- 
low the  exposure.  Careful  cleansing  and  complete  control  of  the  entrance 
of  food  through  the  opening  should  be  maintained,  for  obvious  reasons. 

The  Comments. — Whether  or  not  a  sound  tooth  should  be  sacrificed  to 
afford  a  point  of  entrance,  or  an  opening  of  the  facial  surface  be  made  at 
once,  is  a  matter  of  some  dispute.  In  our  opinion  the  former  plan  will  give 
greater  satisfaction  in  the  majority  of  instances,  because  the  opening  is 
likely  to  exist  for  a  long  time,  and  often  is  permanent.  In  the  latter  class 
of  cases  much  better  control  can  be  had  of  the  exit  and  entrance  of  matters 
than  when  the  opening  is  at  the  facial  surface. 

Tlie  After-treatment. — Thorough  cleanliness  should  be  maintained  by 
frequent  cleansing  of  the  cavity  through  the  opening  until  the  disease  is 
cured.  For  this  purpose  the  aperture  should  not  be  allowed  to  close  until 
final  relief  is  secured,  when,  if  closure  will  follow  without  discomfort,  it  may 
be  encouraged.  A  tube  with  an  adjustable  plug  may  be  worn  in  either  case, 
but  one  connected  with  an  appliance  fitted  to  the  gap  left  in  the  biting  line 
from  the  removal  of  the  tooth  is  less  annoying  and  better  controlled  than 
one  inserted  in  an  opening  at  the  anterior  surface.  A  competent  mechan- 
ical dentist  can  do  much  to  increase  the  comfort  and  efficiency  attending 
the  employment  of  continuous  drainage. 

Operations  on  the  Cervical  Sympathetic  Nerve. — Jnnnesco  describes 
three  degrees  of  operative  practice  on  the  nerve  that  can  be  employed  for 
relief  from  disorders  related  to  the  sympathetic  nerve  influence : 

1.  Simple  incision  ;  3,  jiartial  resection  ;  3,  total  resection.     >• 

Other  surgeons  preceded  Jonnesco  in  the  practice  of  partial  resection, 
limited,  for  example,  to  the  superior  cervical  ganglion  of  both  sides  (Alexan- 
der), the  middle  ganglion  of  the  left  side  (Bojdanick).  Jonnesco  was  first 
to  excise  the  entire  sympathetic  in  the  neck. 

The  Operation. — With  the  shoulders  and  head  raised,  and  the  head  turned 
to  the  opposite  side  and  exposed  to  a  good  light,  make  an  incision  from  the 
posterior  border  of  the  mastoid  process  downward,  along  the  posterior  mar- 
gin of  the  sterno-cleido-mastoid  to  a  point  a  little  below  the  clavicle ;  expose 


M ISCELLAN KOUS  OPEKATIONS. 


1283 


and  ilivide  the  external  jugular  vein  between  twu  ligatures;  isolate  the  pos- 
terior border  of  the  sterno-mastoid  and  split  it  in  the  continuity  of  the 
structure  near  to  the  margin  ;  separate  tlie  deeper  tissues  along  the  line  of 
incision,  carefully  avoiding  injury  to  the  associated  vascular  and  nervous 
structures;  draw  apart  the  borders  of  the  wound  and  seek  for  the  nerve 
near  the  middle  of  the  wound  as  it  lies  in  its  established  relations  with  the 
sheath  of  the  carotid,  the  longus  colli,  and  scalenus  anticus  muscles  (Fig. 
1552);  expose  and   follow  upward  the  trunk  of  the  nerve  to  the  superior 


Fig.  1.5o2.— The  cervical  sympathetic  nerve  and  ganglia,  a.  Superior  cervical  ganglion. 
b.  Branch  of  cervical  plexus,  c.  Sterno-mastoid  muscle,  d.  Common  carotid  artery 
in  sheath,  e.  Pneumogastric  nerve  in  sheath.  /.  Internal  jugular  vein  in  sheath. 
g.  Branch  of  sympathetic.  /(.  Inferior  thyroid  artery,  i.  Inferior  cervical  ganglion. 
J.  Verteln-al  artery  and  vein.     k.  Phrenic  nerve. 

ganglion  (a) ;  isolate  the  ganglion,  divide  its  communicating  filaments  and 
those  of  the  exposed  trunk  of  the  nerve,  and  remove  the  ganglion  and 
the  trunk ;  seize  with  forceps  the  distal  end  of  the  lower  part  of  the  trunk 
and  put  it  upon  the  stretch  ;  separate  downward  carefully  the  trunk  from 
the  contiguous  tissues  to  the  inferior  thyroid  artery ;  dissociate  cautiously 
the  artery  from  the  intimate  intervals  of  nerves,  in  the  midst  of  which  may 
87 


1284 


OPERATIVE  SURGERY. 


be  found  and  isolated  the  middle  cervical  ganglion  (Fig.  1553) ;  trace  still 
further  downward  the  main  trunk  deeply  into  the  neck  and  seek  for  the  infe- 
rior ganglion  where  it  lies  behind  the  clavicle,  closely  associated  with  the  head 
and  neck  of  the  first  rib  and  the  pleura  beneath  (Fig.  1554) ;  apply  a  retractor 

at  either  side  of  the  wound  so  as 
A  \\»\\M\\\MM\iii*l  to  include  externally  the  scalenus 
anticus  muscle,  thyroid,  supra- 
scapular, and  vertebral  arteries 
and  veins;  at  the  inner  side  the 
sterno-cleido-mastoid  muscle  and 
deep  vessels ;  grasp  with  forceps 
and  free  the  ganglion  by  blunt  dis- 
section from  the  vertebral  vessels 
without  and  the  costo-vertebral 
structures  within  ;  divide  with 
small,  blunt- pointed  scissors  the 
ramifications  of  the  ganglion,  cau- 
tiously shunning  the  important 
contiguous  structures,  and  remove 
it  along  with  the  portion  of  trunk 
attached  above  ;  arrest  haemor- 
rhage and  unite  the  borders  of 
the  wound  by  deep  and  superficial 
sutures;  dress  the  wound  asepti- 
cally,  confine  the  head  and  neck 
closely,  and  quiet  the  patient  with 
an  anodyne. 

The  Precanfions.  —  Thorough 
asepsis  and  a  clear  appreciation  of 
the  anatomy  embraced  in  the  pro- 
cedure are  essential  requirements. 
Involvement  of  the  pleura  and  im- 
2:)ortant  vessels  and  nerves  is  to  be 
avoided.  Be  not  too  confident  of 
a  favorable  therapeutic  outcome. 

The  Bern  arks.  —  Jonnesco  re- 
gards apjiroaeh  to  the  nerve  by 
splitting  the  posterior  border  of  the  sterno-mastoid  muscle  as  less  trouble- 
some than  exposure  of  and  passing  under  the  border.  The  superior  ganglion 
is  the  largest  of  the  three,  is  located  opposite  the  second  and  third  cervical 
vertebrae,  sometimes  as  low  as  the  fourth  or  fifth.  It  lies  behind  the  sheath 
of  the  carotid  and  upon  the  rectus  capitus  anticus  major  muscle.  The  mid- 
dle ganglion  is  the  smallest  of  the  three  and  is  sometimes  wanting.  It  is 
located  opposite  the  sixth  cervical  vertebrae,  is  closely  associated  with  the 
inferior  thyroid  artery,  hence  denominated  thyroid  ganglion.  The  inferior 
cervical  ganglion  is  situated  between  the  base  of  the  transverse  process  of 
the  last  cervical  vertebra  and  the  neck  of  the  first  rib  at  the  inner  aspect  of 


Fig.  155:1 — The  middle  cervical  ganglion  of 
cervical  sympathetic  nerve,  a.  Common 
carotid  artery  in  sheath,  h.  Pneumogas- 
tric  nerve  in  sheath,  c.  Internarl  jugular 
vein  in  sheath,  d.  Sympathetic  nerve. 
e.  Inferior  thyroid  artery.  /.  Middle  cer- 
vical ganglion,  g.  Vertebral  vein.  h. 
Scalenus  anticus  muscle,     i.  Thyroid  axis, 


MiSCKLLANHors   OI'KKATIONS. 


1285 


tlie  siijxM-ior  intoreoslal  iirtory.  It  is  next  iu  size  to  the  superior  gangliou. 
Tiie  inferior  ganglion  usuully  lies  inside  the  vertebral  artery  and  invests  this 
vessel  with  its  biaiiclies.  Sometimes  this  ganglion  is  friable  and  removed 
piecemeal. 

The  licsnlts. — Juidicsco  reports  the  following  outcome  secured  bv  him- 
self and  others  in  this  o])eration  : 

1.  Simple  incision  has  been  done  by  Jaboulay  three  times  with  good  opera- 
tive results,  but  the  possibility  of  regeneration  at  the  seat  of  division  makes 
this  method  of  practice  untrustworthy. 

'i.  Partial  Resection. — All  the  nerves  down  to  the  thyroid  artery  and  the 
superior  ganglion  have  been  removed  12  times  by  six  different  operators. 
In  14  cases  5  are  reported  cured,  2  relapsed,  and  7  not  definitely  stated. 
Jonnesco  reports  7  instances  practiced  for  glaucoma,  in  all  of  which  the 
operation  was  limited  to  the  superior  ganglion.     Post-operative  effects  slight 


Fig.  1554. — The  inferior  ocrvioal  gansrlion  and  the  sympathetic  nerve,  a.  Internal  jugu- 
lar vein  in  sheatii.  h.  Pneunioj^astric  nerve  in  slieath.  c.  Internal  juguhir  vein  in 
sheath,  d.  Middle  cervical  ganglion,  e.  Vertebral  nerve.  /.  Inferior  cervical  gan- 
glion,    h.  Vertebral  artery  and  vein.     g.  Inferior  thyroid  artery. 


and  transitory.     Immediate  reduction  of  intraocular  tension  and  progressive 
amelioration  of  vision  followed.      Jonnesco  also  reports  26  epileptics  who 


1286  OPERATIVE  SURGERY. 

were  subjected  to  the  operation.  lu  "some  cases  "  the  cure  was  maintained 
for  a  year,  others  were  notably  improved  both  as  to  frequency  of  fits  and 
mental  state.     All  were  improved  and  no  case  was  made  worse. 

Rehn  reports  32  cases  of  Graves's  disease  treated  by  operation  on  the 
cervical  sympathetic  with  28.1  per  cent  cured,  50  per  cent  improved,  12.5 
per  cent  not  relieved,  and  9.3  per  cent  died.  He  also  shows  that  above 
twice  as  many  cases  follow  thyroid  extirpation  as  attend  operation  on  the 
sympathetic  with,  however,  a  higher  rate  of  mortality,  viz.,  13.6  per  cent, 
and  9.3  per  cent  respectively. 

The  removal  of  foreign  bodies  from  the  hand  and  elsewhere  about  the 
human  body  through  a  longitudinal  incision  made  directly  down  upon  the 
supposed  site,  and  by  means  of  a  > -shaped  incision  so  placed  that  the  apex 
of  the  >  should  conform  with  the  point  of  entrance  of  the  foreign  body  and 
the  limbs  to  its  direction  in  the  tissues,  and  located  so  as  to  include  in  the 
triangular  flap  the  object  sought  for,  are  methods  of  practice  of  good  repute, 
long  since  established.  The  employment  of  these  methods  has,  however, 
been  followed  by  disappointed  effort  in  the  search  and  by  severe  after- 
effects. The  advent  of  the  X  ray  reduced  the  hitherto  uncertain  outcome  of 
sightless  operative  effort  to  the  basis  of  substantial  scientific  success  in  all 
instances.  But  a  single  instance  is  needed  to  illustrate  the  plan  of  action 
employed  by  the  writer.    In  this  particular  instance  long,  tedious,  and  uusuc- 


PiG.  1555.— Locating  in  right  hand  a  foreign  body  by  the  X  ray,  palmar  view.  Scar 
indicated  by  longitudinally  placed  pin.  Area  divided  into  equal  spaces  by  three 
transversely  placed  pins.     Foreign  body  seen  at  ulnar  side  of  longitudinal  pin. 

cessful  search  under  general  anaesthesia  had  failed  to  locate  a  fragment  of 
broken  needle.  In  this,  as  in  other  instances,  a  fine  needle  was  carried 
superficially  through  the  toughened  cuticle  in  the  long  axis  of  the  scar 
caused  by  the  previous  effort.  This  step  caused  no  pain  and  the  needle  was 
held  securely  in  place.  Three  additional  needles  were  then  passed  through 
the  cuticle  at  right  angles  to  the  preceding  needle  at  definite  equal  distances 
from  each  other,  thus  dividing  the  corresponding  area  into  four  equal  spaces. 


MISCELLAN HOI'S   OlMOKATIUNS. 


1287 


An  X-ray  photograph  was  tlicn  made  of  the  palmar  and  hiteral  aspects  of  tlie 
liaiid  (Figs,  lo.")")  and  l,").")!".),  showing  tlie  deptli  in  the  tissues  of  tlie  foreign 
botly  and  its  comparative  rehition  to  the  toi)ographY  outlined  by  tlie  needles. 


Fig.  155G.— Local  ins  in  right  hand  a  foreign  body  with  X  ray.  side  view.     Showing  depth 
of  foreign  body  and  its  relation  to  the  pins  on  palmar  surface. 

The  proper  seat  of  incision  for  removal  of  the  foreign  body  is  thus  made 
obvious,  and  one  has  but  to  adhere  to  the  line  of  incision  without  deviation 
with  an  abiding  faith  in  success. 

The  Remarks. — The  extremity  should  be  placed  in  a  even  manner  on  a 
horizontal  surface  when  photographed.  After  the  picture  is  taken  the 
needles  should  be  removed  and  their  respective  sites  indicated  on  the  sur- 
face for  subsequent  observation. 


INDEX 


Abbe's   met  hod   of   intestinal   anastomosis, 

644. 
Abbe's  o|>eriitioii  for  division  of  (esopliageal 

strieture,  ()(K$. 
Abdomen,  stub  wounds  of,  607. 

contused  wounds  of,  668. 

paraetMitesis  of,  895. 
Abdominal  section,  607. 

exploratory,  618. 

for  penetrating  gunshot  wounds,  650. 

for  wounds  of  abdominal  viscera,  650. 

in  intestinal  obstruction,  669,  670. 

in  treatment  of  intussusception,  693. 

instruments  employed  in,  609. 
Abdominal  wall,  hernia  of,  898. 
Abscess,  ischio-rectal,  967. 

of  liver,  793. 

of  lung,  1039. 

of  neciv,  1098. 
Abscess,  prostatic,  1144. 
Abscess,  psoas,  1358. 
Abscess,  retropharyngeal,  1099. 

Buckhardt's  operation  for,  1099. 

Chiene's  operation  for,  1099. 
Abscess,  subphrenic,  893. 

abdominal  incision  for,  893. 

thoracic  incision  for,  894. 
Agnew's  operation  for  salivary  fistula,  563. 
Air-passages,  foreign  bodies  in,  1076. 
Albarran's  vasectomy  for  relief  of  prostatic 

hypertrophy,  1142. 
Alexander's    operation    of    prostatectomy, 

1137. 
Allingham's  bone  bobbin  for  intestinal  ap- 
proximation, 635. 
Allingham's  operation  for  cure  of  haemor- 
rhoids, 958. 
Allingham's  operation  in  perineal  proctec- 
tomy, 988. 
Alsberg's  operation  for  relief  of  stricture  of 

ureter,  873. 
Amputation  of  penis,  1232. 

an  ohl  method,  1223. 

Davies-C'ollv's  method,  1224. 

flap  method,  1223. 

Hilton's  method,  1223. 

IIum|)hrev's  method,  1223. 

Thiersch's  method,  1224. 
Amputation  of  rectum  for  prolapse  : 

Kleberg's  method,  979. 

Mikulicz's  method,  978. 

Treves's  method,  978. 


Amussat's  operation  of  left  lumbar  colosto- 
my, 682. 
.Xnu'sthesia,  local,  in  operation  on  hernia, 
942. 
Schleich's  infiltration  method,  942. 
Anastomosis,  intestinal,  by  lateral  implan- 
tation, (i48. 
Anastomosis,  intestinal,  end-to-end,  624. 
by  bone  bobbin  (Allingham),  635. 
by  bone  l)obbin  (Hayes),  636. 
by  bone  bobbin  (liobson),  635. 
by  India-rubber  tube  (Robinson),  637. 
by  Laplace's  method,  632. 
by  ^Maunsell's  method.  625. 
by  Murphy's  method,  62J). 
of  unequal  segments,  637. 
Anastomosis,  intestinal,  lateral,  630. 
by  enterotome  (Grant),  648. 
by  Laplace's  method,  634. 
by  Murphy's  button,  630. 
by  potato  plates  (Dawbarn),  641. 
by  Senn's  method,  637. 
by  sewing  only  (Abbe),  644. 
by  sewing  only  (Halsted),  645. 
with  segmented  rubber  plates  (Robinson), 
643. 
Anastomosis,  lateral,  of  intestine,  in  treat- 
ment of  intussusception.  695. 
.Andrew's  method  of  gastrostomy,  752. 
Anger's  operation  for  cure  of  hvpospadias, 

1236. 
Annandale's  operation  for  removal  of  naso- 
pharyngeal  polypi   by   palatine   route, 
585. 
Anus,  absence  of,  947. 
Anus,  artificial,  731. 

Bodine's  operation  for  cure  of,  735. 
Greig  Smith's  ojieration  for  cure  of,  734. 
in  treatment  of  intussusception,  695. 
making  of  (Kocher).  672. 
vicarious  sphincteric,  control  after,  996. 
Anus,  fistula  of.  949. 
Anus,  imperforate,  946. 

operation  for  relief  of,  947. 
Appendicitis,  acute  catarrhal,  722. 
Appendicitis,  acute,  characterized  by  sud- 
den perforation  and  diffuse  septic  peri- 
tonitis. 715. 
Appendicitis,   acute,    usually   accompanied 
with  perforation,  attended  with  more 
or  less  circumscribed  suppuration,  and 
possibly  abscess,  717. 

1289 


1290 


OPERATIVE  SURGERY. 


Appendicitis,  acute,  with    perforation  and 
circumscribed   suppurative  peritonitis. 
719. 
Appendicitis,  recurring  or  relapsing,  720. 
Appendix  vermiformis.  removal  of.  708. 
Dawbarn's  method  of  treating  stump,  714. 
Fowler's  method  of  treating  slump.  714, 

715. 
McBurnev's  method   of   treating   stump, 

714. 
McCosh's  method  of  treating  stump,  714. 
Appendix  vermiformis,  removal  of,  during 

interval  of  attacks,  723. 
Appendix  vermiformis,  removal  of,  incisions 
for,  713. 
Battle's,  724 
Elliot's,  723. 
Fowlers.  725. 
Jalaguier's.  724. 
Kammerer's,  724. 
McBurney's  gridiron,  721. 
Meyer's  hockey-stick,  725. 
modified,  723. 
Vischer's,  724. 
Weir's,  723. 
Artificial  anus.  Kocher's.  672. 
Artificial  larynx.  Gussenbauer's.  1086. 
Artificial  respiration.  Fell-O'Dwyer  appara- 
tus for  inducing.  1033. 
Ascites  from  cirrhosis  of  liver  : 

operation  for  cure  of.  802. 
Aspiration  of  bladder,  1116. 
Aspiration  of  pericardium,  1055. 
Aspiration  of  pleural  cavity  combined  with 
drainage,  1026. 

Bacon's  method  of  internal  proctotomy.  984. 
Baracz's  operation  for  intussusception.  698. 
Barker's  method  of  treating  fractured  pa- 
tella. 1266. 
Barker's  operation  for  intussusception,  696. 
Bassini's     operation    for    radical    cure    of 

femoral  hernia.  938. 
Bassini's  operation  for  radical  cure  of  her- 
nia. 922. 
Battle's  incision  for  removal  of  appendix 

vermiformis.  724. 
Baumm's    extraperitoneal    method    of    im- 
planting ureters  into  bladder.  859. 
Belfield's  operation  of  prostatectomy,  1135. 
Bennett's  modification  of  Howse's  operation 

for  radical  cure  of  varicocele,  1231. 
Bigelow's  operation  for  relief  of  extrover- 
sion of  bladder,  1149. 
Biliary  fistula,  823. 

Billroth's  operation  for  relief  of  extrover- 
sion of  bladder,  1153. 
Bircher's  method  of  gastroplication,  782. 
Bladder,  aspiration  of.  1116. 
Bladder,  drainage  of.  1123. 

Dawbarn's  apparatus  for,  1127. 
Gibson's  method,  1126. 
perineal,  1124. 
per  urethram.  1123. 
suprapubic.  1125. 
Bladder,  extirpation  of.  1155. 
Bladder,  extroversion  of.  1145. 

Bigelow's  operation  for  relief  of,  1149. 


Bladder,  extroversion  of,  Billroth's   opera- 
tion for  relief  of,  1153. 
Greig  Smith's  operation  for  relief  of.  1152. 
]\Iaury's  operation  for  relief  of.  1148. 
Pousson's  operation  for  relief  of.  1153. 
Robson's  modification  of  Wood's   opera- 
tion for  relief  of.  1150. 
Segond's  modification  of  Thiersch's  opera- 
tion for  relief  of,  1152. 
Thiersch's  operation  for  relief  of,  1152. 
Wood's  operation  for  relief  of,  1149. 
Bladder,  extroversion  of.  approximation  of 
innominate  bones  for  relief  of,  1154. 
Trendelenburg's  method.  1154. 
Bladder,  foreign  bodies  in.  1205. 
Bladder,  introduction  of  sounds  and  cathe- 
ters into,  1109. 
Bladder,  operations  on  the.  1108. 
Bladder,  puncture  of.  1115. 
by  direct  incision.  1115. 
by  suprapubic  route.  1115. 
through  rectum.  1116. 
under  the  pubes.  1116. 
with  a  trocar,  1115. 
Bladder,  rupture  of.  1117. 
extraperitoneal.  1117. 
intraperitoneal.  1117. 
Bladder,  stone  in.  1156. 
Bladder,  tumors  of.  cystotomy  for,  1119. 
Bloodgood's  modification  of  Halsted's  opera- 
tion for  radical  cure  of  inguinal  hernia, 
922. 
Bodine's  operation  of  iliac  colostomy.  679. 
Boeckel's  operation  for  radical  cure  of  um- 
bilical hernia,  139. 
Boeckel's   operation   for   removal  of   naso- 
pharvngeal  polvpi  bv  maxillary  route, 
585.  ■ 
Bone  bobbins  for  intestinal  anastomosis. 
AUingham's,  635. 
Haves's.  636. 
Robson's.  635. 
Bones,  long,  fracture  of.  method  of  uniting, 

1272. 
Borelius's   method   of   sacral   proctectomv, 

993. 
Bottini's  operation  for  radical  cure  of  femo- 
ral hernia.  938. 
Bottini's  iise  of  galvano-cautery  for  relief  of 

prostatic  hypertrophy,  1143. 
Bovee's  method  of  uretero-ureteral  anasto- 
mosis, 854. 
Braun's  method  of  gastro-enterostomy,  758. 
Breast,  excision  of.  1003. 
Chevne's  incision  for.  1006. 
Tlalsted's  method.  1009. 
instruments  used  in.  1006. 
Kocher's  incision  for.  1006. 
Meyer's  method.  1013. 
Senn's  incision  for.  1006. 
Warren's  incision  for.  1006. 
Breast,  excision   of   non-malignant  tumors 
of.  1020. 
Thomas's  method.  1020. 
Brigham's  operation  for  complete  gastrec- 
tomy. 789. 
Bronchi,  foreign  bodies  in,  1076. 
Bronchial  cysts,  1105. 


INDFA'. 


1291 


Bronchiectasis,  operation  for  relief  of.  1041. 

Hroncliotoiny.  lO.")!). 

liryaiit's  |.l.    I).).  (iperatiDii   for  division  of 

u'sopliajjeal  stricture,  (504. 
Bryant's  (J.  D.),  nietliod  of  as[)iration  with 

ilraiiiaire  of  pleural  cavities  for  cure  of 

eiupyeuui.  1()',M!. 
Ruckhardt's  operation  for  retropharvngeal 

abscess,  1100. 

Cjecal  hernia,  941. 

Calculus  of  ureter,  8C7. 

Caries  of  ribs,  1031. 

Caries  of  sternum,  1031. 

Castration,  1214. 

Castration  for  i-elief  of  prostatic  hvper- 
trophv,  1142. 

Catheter,  care  of,  1108. 

Catheters,  introduction  into  bladder,  1109. 

Ceci's  method  of  treating  fractured  patella, 
1268. 

Cervical  Ivmphatic  glands,  diseased,  re- 
moval" of,  1100. 

Cervical  sympathetic  nerve,  operations  on, 
1282. 

Chalot's  operation  for  removal  of  naso- 
pharvngeal  polypi  bv  palatine  route, 
584.  " 

Chaput's  method  of  iinfilanting  ureter  into 
bowel,  862. 

Chapufs  operation  for  enteroplasty,  674. 

Chassaignac's  operation  for  removal  of  naso- 
pharyngeal polvpi  bv  palatine  route. 
582. 

Cheever's  operation  of  pharyngotomy,  576. 

Cheever's  operation  for  removal  of  naso- 
pharyngeal polypi,  by  nasal  route,  587. 

Chevne"s  incision  for  excision  of  breast, 
'1008. 

Chiene's  operation  for  retropharvngeal  ab- 
scess, 1099. 

Chismore's  method  of  litholapaxy  and 
evacuation,  1173. 

Cholangiostomy.  802. 

Choice vstectoniv,  810. 

Cholecystendysis,  809. 

Choice vstenterostomv.  811. 

Cholecyst-lithotrity.  813. 

Cholecystotomy,  805. 
use  of  Murphy's  button  in,  807. 

Choledocho-enterostomv,  819. 

Choledocho-lithotomv.  813. 

Choledocho-lithotrity,  814. 

Choledochorrhaphy  (Doyen),  821. 

Choledochotoray,  815. 
Halsted's  operation,  816. 
Lumliar  route.  822. 

Cholelithotrity.  813 

Circumscision.  1217. 
Keyes's  method,  1218. 

Coates's  operation  for  cure  of  haemorrhoids, 
960. 

Cceliotomy,  607. 

Colectomy.  702. 

Paul's  operation  for,  703. 

Coley's  operation  for  radical  cure  of  femoral 
hernia,  937. 

Colon,  transverse,  colostomy  of,  682. 


Colon,  transverse,  operations  on  the,  706. 
Colopexy.  9M2. 
Colori'ctostomv,  KXJl. 

sacral.  1002." 
Colostomy,  675. 

of  the  transverse  colon,  682. 
Colostomy,  iliac.  Littre's,  675. 

Bodine's  method,  679. 

Cripps's  method.  680. 

Reclus's  methoil,  681. 
Colostomy,  iliac,  right.  682. 
Colostomy,  lumbar,  left  (Amussat),  683. 
Colostomy,  lumbar,  right,  688. 
Contused  wounds  of  abdomen,  668. 
Contused  wounds  oi  intestine,  668. 
Cripps's  operation  of  iliac  colostomy,  680. 
Cusack's  operation  for  cure  of  ha'uiorrhoids, 

961. 
Cushing's  intestinal  suture,  621. 
Cvstico-lithotomv,  815, 
Cystotomy.  1118." 

for  tumors.  1119. 

perineal.  1118. 

suprapubic.  1119. 
Cystotomy,  supra[>ubic,  1115. 
Cysts,  branchial.  1105. 
Czerny-Lembert's  intestinal  suture,  621. 
Czerny's  modification  of  pylorectomy,  com- 
bined with  gastro-enterostomy,  774. 
Czerny's  operation  of  pharyngotomy,  577. 

Dauriac's  transference  method  of  operating 
for  radical  cure  of  umbilical  hernia.  989. 

Davies-Colly  operation  for  amputating 
penis,  1224. 

Dawbarn's  apparatus  for  draining  bladder, 
I  1127. 

Dawbarn's  method  of  intestinal  approxima- 
I  tion  by  potato  plates,  641. 

Daw])arn's  method  of  treating  stump  of  ap- 
jiendix,  714. 

Deaver's  operation  for  radical  cure  of  ingui- 
nal hernia,  931. 

Delorme's  modification  of  Estlander's  oper- 
ation on  chest  wall,  1030. 

Delpech's  method  of  urethroplasty.  1246. 

Dequise's  operation  for  salivary  fistula,  564. 

Desault's  operation  for  salivary  fistula.  563. 

Diaphragm,  hernia  of.  1035. 

Diaphragm,  wountls  of.  1036. 

Dieifenbach's  method  of  urethroplasty,  1246. 

Dilatation  of  cardiac  orifice  of  stomach,  780. 

Dittel's  method  of  urethroplasty,  by  flap 
sliding,  1246. 

Dittel's  operation  of  prostatectomy.  1136. 

Dittel  and  Zuckerkandl's  operation  for  re- 
lief of  prostatic  abscess,  1144. 

Doyen's  method  of  choledochorrhaphy,  821. 

Drainage  of  peritoneal  cavity.  613. 

Duodenum,  gunshot  wounds  of,  667. 

Duplav's  method  of  repairing  epispadias, 
1243. 

Duplav's  operation  for  cure  of  hypospadias, 
1236. 

Elbowing  of  intestine  : 
Chaput's  method.  674, 
Jeannel's  method,  673. 


1292 


OPERATIVE  SURGERY, 


Elephantiasis  of  scrotum.  1232. 

Elliot's  incision  for  removal  of   appendix. 

723. 
Emmet's  method  of  uretero-ureteral  anasto- 
mosis, 857. 
Empvema,  aspiration  and  drainage  for  cure 

of,  1026. 
Empyema,  chronic  : 

Delorme's  operation  for  cure  of.  1030. 

Estlan<ler's  operation  for  cure  of.  1020. 

Fencer's  operation  for  cure  of.  1030. 

Sehede's  operation  for  cure  of,  1029. 
Enterectomy.  658. 

Halsted's  method.  662. 

Kocher's  method.  659. 
Entero-anastomosis   in  gastro-enterostomy, 
758. 

Braun's  method,  758. 

Jaljoulay's  method.  758. 

Lowenstein's  method,  758. 

use  of  Murphy's  button  in,  763,  765. 

Wolfler's  method.  758. 
Enteroplasty,  673. 

Chaput's  method,  674. 

Jeannel's  method.  673. 
Enterorrhaphv,  circular.  Harris's  operation 

for.  663.  ■ 
Enterostomy,  670. 

Kocher's  method,  670. 
Enucleation  of  thyroid  (Sociu).  1092. 
Enucleation — resection  of  thvroid  (Kocher), 

1091. 
Epispadias,  1239. 

Duplay's  method  of  repair,  1243. 

Nelaton's  method  of  repair,  1240. 

Thiersch's  method  of  repair.  1241. 
Erichsen's  operation  for  radical  cure  of  vari- 
cocele, 1229. 
Estlander's  operation   for   cure  of   chronic 

empyema.  1029. 
Excision  of  breast.  1003. 

Cheyne's  incision  for.  lOOS. 

conservative  method.  1016. 

Halsted's  operation  for.  1009. 

instruments  used  in,  1006. 

Kocher's  incision  for,  1006. 

Meyer's  operation  for.  1013. 

Senn's  incision  for.  1006. 

Warren's  incision  for.  1006. 
Excision  of  non-malignant  tumors  of  breast, 
1020. 

Thomas's  method.  1020. 
Excision  of   sympathetic  nerve  for  exoph- 
thalmic goitre  (Jaboulav  and  Jonnesco), 
1094. 
Excision  of  thyroid,  partial  (Kocher).  1087. 
Excision   of    thvroid.    bv  angular   incision 

(Kocher),  1088. 
Exothyropexy  (Jaboulav).  1094. 
Extirpation  of  parotid  gland.  1105. 
Extroversion  of  bladder,  1145. 

Bigelow's  operation  for  relief  of,  1149. 

Billroth's  operation  for  relief  of.  1153. 

Greig  Smith's  operation  for  relief  of.  1152. 

Maury's  operation  for  relief  of.  1148. 

Pousson's  operation  for  relief  of.  1153. 

Thiersch's  operation  for  relief  of.  1152. 

Wood's  operation  for  relief  of,  1149. 


Extroversion  of  bladder,  approximation  of 
innominate  bones  for  relief  of.  1154. 
Trendelenburg's  method,  1154. 

Fiecal  fistula,  731. 

Fa?cal  fistula,  enterostomy  Kocher's  (meth- 
od). 670. 
Fell-O'Dwyer.  apparatus  for  inducing  forced 

artificial  respiration.  1033. 
Femur,  nailing  the  head  of,  for  relief  of 

fracture.  1276. 
Femoral  hernia,  operation  for  radical  cure 
of,  936. 
Bassini's  method,  936. 
Bottini's  method.  938. 
Colev's  method.  937. 
Gordon's  method,  938. 
Kocher's  method.  937. 
Lowenstein's  method.  938. 
Trendelenburg's  method.  938. 
Femoral  hernia,  strangulated.  909. 

taxis  in.  910. 
Fenger's  operation  for  cure  of  chronic  em- 
pyema, 1030. 
Fenger's  operation  for  relief  of  stricture  of 

ureter.  873. 
Fenger's  operation  for  relief  of  valve  forma- 
tion in  ureter,  871. 
Fistula,  fjpcal.  731. 

Bodine's  operation  for  cure  of.  679. 
Greig  Smith's  operation  for  cure  of,  734. 
Fistula  in  auo,  949. 

operation  for  relief  of.  951. 
Fistula,  salivary.  563. 
Agnew's  operation  for  relief  of.  563. 
Dequise's  operation  for  relief  of,  564. 
Desault's  operation  for  relief  of,  563. 
operation  by  a  seton.  563. 
Richelot's  operation  for  relief  of.  564. 
Van  Buren's  operation  for  relief  of.  564. 
Fistula,  urethral,  Szvmanowski's  method  of 

repair,  1238. 
Foreign  bodies  in  air  passages.  1076. 
Foreign  bodies  in  bladder.  1205. 
Foreign  bodies  in  oesophagus.  591. 
Foreign   bodies    in   the   hand,  removal   of, 

1286. 
Foreign  bodies  in  the  urethra.  1203. 
Fowler's  incision  for  removal  of  appendix, 

725. 
Fowler's  method  of  implanting  ureter  into 

bowel.  863. 
Fowler's  method  of  treating  stump  of  ap- 
pendix. 714.  715. 
Fowler's  operation  for  radical  cure  of   in- 
guinal hernia.  932. 
Fractures  of   bone,  pegging   for   relief  of. 

1274. 
Fracture  of  long  bones,  methods  of  uniting, 

1272. 
Fracture  of  olecranon  process,  suture  for, 

1271. 
Fracture  of  patella,  old.  1268. 
Fracture  of  patella,  suture  for.  1260. 
Fractured  patella : 

Barker's  method  of  treatment.  1266. 
Ceci's  method  of  treatment,  1268. 
Stirason's  method  of  treatment,  1266. 


INDKX. 


1208 


Frank's  oponition  of  nc|ilii<i|)<>xy,  831. 
Frontal  sinus,  operations  on,  128U. 

Gal!  Ijliuldor,  operations  on,  803. 

cholecvstectoniv,  810. 

eiioieeystcndysis.  H(»'J. 

elioleevstenlerostnniy.  811. 

ciiolee'ysl-litliotrity.  813. 

cliolei-ystotoiny.  80o. 

tappinj^  and  aspiiatioii,  804. 
Gan-^rene  of  hni",'.  10-12. 
Gastro-anastoiMosis.  781. 
Gastrectomy,  eoiniilete.  788. 

Brif,dianrs  method,  781). 

Kiflianlson's  method.  790. 

Sfidalter's  method,  788. 
Gastric  nicer.  784. 

non-perforating,  operation  for,  786. 

operation  for  control  of  hajuiorrhage  in, 
787. 

perforating,  operation  for,  784. 
Gastro-anastomosis,  781. 
Gastro-enterostomy,  753. 

Braun's  inetiiod.  758. 

Jal)oulay"s  modification,  758. 

Kappeler's  modification,  764. 

Kocher's  method.  759. 

Lowenstein's  modification,  758. 

Roux's  method,  7G3. 

Soiuienberg's  method,  761. 

Von  Hacker's  method  (posterior),  761. 

WolHer's  modification.  758. 
Gastro-enterostomy,  combined  with  pylorec- 

tomy,  773. 
Gastro-gastrostomy,  781. 

Watson's  method,  781. 

Wolfler's  method,  781. 
Gastropexv,  784. 
Gastroplasty.  782. 
Gastroplication,  782. 

Bircher's  method,  782. 

Moynihan's  method,  783, 

Weir's  method.  783. 
Gastrorrhaphy,  782. 
Gastrostomy.  741. 

Andrew's  method,  752. 

Ilahn's  ofieration.  749. 

Kader's  operation,  750. 

Marwedel's  method,  752. 

Senn's  (E.  J.)  operation,  749. 

Stamm's  operation,  752. 

Ssabanejew-Franck  operation,  748. 

Witzel's  operation,  746. 
Gastrostomy,  incisions  for : 

Girard's.  746. 

Von  Hacker's,  746. 
Gastrotomy,  738. 

Gely's  intestinal  suture,  620. 
Gersiiny's  method   for  obtaining  vicarious 
sphincteric  control  after  proctectorav. 
996. 
Gibson's  method  of  draining  bladder,  1126. 
Girard's  incision  for  gastrostomy.  746. 
Gland,  parotid,  extirpation  of,  1105. 
Glands,  lymphatic,  of  neck,  removal  of.  1100. 
Goitre,  excision  of  sympathetic,  for  relief  of, 

(Jaboulay  and  Jonnesco),  1094. 
Goitre,  injection  for  relief  of,  1094. 


Goitre,    resection     of     thvroid     b.idv     for 

(Kocher),  1093. 
Goitre,  treatment  l)y  ligature  of  thyroid  ar- 
teries (Kociier).'  1094. 
Gordon's  operation  for  radical  cure  of  femo- 
ral hernia,  938. 
Gould's  method  of  extir|)ating  penis,  1225. 
Goulev's     method     of     extirpating     penis, 

1226. 
Goulev's   operation    of     external    perineal 

urethrotomy.  1249. 
Goulev's    o])eration    for   cure   of    hvpospa- 

dias,  1235. 
Grafting,  omental,  674. 
Grant's  method  of  intestinal   anastomosis, 

648. 
Gridiron    incision   for   removing   appendix 

(Mcl'.urney),  721. 
Greig  Smith's  operation  for  radical  cure  of 

und)ilical  hernia.  938. 
Greig  Smith's  operation  for  radical  cure  of 

ventral  hernia,  940. 
Guerin's   operation    for   removal    of    naso- 

pharvngeal  polv[)i  bv  maxillarv  route, 

587.  ■ 
Gunshot  wounds  of  duodenum,  567. 
(iimshot  wounds  of  large  intestine.  667. 
Gunshot  wounds,  penetrating,  of  abdomen, 

650. 
Gussenbauer's  artificial  larynx,  1086. 
Gussenbauer's  intestinal  sutures,  622. 

Ha-mothorax,  1037. 

Ilahn's  operation  of  gastrostomy,  749. 

Ilalsted's  hammer,  816. 

Halsted's  mattress  or  quilt  intestinal  suture, 
622. 

Ilalsted's  method  of  intestinal  anastomosis, 
648. 

Halsted's  operation  for  excision  of  breast, 
1009. 

Halsted's  operation  for  radical  cure  of  in- 
guinal hernia.  919. 

Ilalsted's  operation  for  resection  of  intes- 
tine. 662. 

Halsted's  operation  of  choledochotomy,  815. 

Harris's  method  of  catheterizing  ureter,  886. 

Harris's    operation    for    circular    enteror- 
rhaphy,  663. 

Harrison's    method  of    perineal    lithotrity 
with  litholapaxy.  1179. 

Hartley's  method  of  removing  diseased  cer- 
vical lymphatic  glands,  1103. 

Ilartmann's  method  of  internal  proctotomy, 
987. 

Hayes's  bone  bobbins  for  intestinal  approxi- 
■  mation,  636. 

Heart,  operations  on.  1054. 

Heart,  wounds  of.  1057. 

Heineke-Mikulicz  operation  of  pyloplasty, 
777. 

Heineke's  operation  in  .sacral  proctectomy, 
991. 

Hajraorrhoids,  957. 

Haemorrhoids,  operations  for  relief  of : 
Allingham's  method,  958. 
Clamp  and  cautery  method  (Cusack).  961. 
Coates's  method,  960. 


1294 


OrEKATIVE  SURGERY. 


Haemorrhoids,  operations  for  relief  of,  crusli- 
ing  method  (Pollock),  960. 

excision  metiiod.  !»5S. 

incision  metluKl.  9oN. 

injection  method.  901. 

ligature  method,  'JGO. 

Whitehead's  method,  959. 
Hepatectomy.  797. 
Hepaticostomy,  815. 
Hepatopexv,  802. 
Hepatostomy.  802. 
Hepatotomy.  797. 
Hernia,  ca^cal.  941. 

Hernia,  femoral,  operation  for  radical  cure 
of,  986. 

Bassini's  method,  936. 

Bottini's  method,  938. 

Coley's  method,  937. 

Gordon's  method,  938. 

Koclier's  method.  937. 

Lowenstein's  metiiod,  938. 

Trendelenburg's  method,  938. 
Hernia,  femoral,  strangulated,  909. 

taxis  in,  910. 
Hernia,  following  appendicitis.  941, 
Hernia,  inguinal,  operation  for  radical  cure 
of.  91.5. 

Bassini's  method,  915. 

Bloodgood's    modification    of     Halsted's 
method,  922. 

Deaver's  method,  931. 

Fowler's  method,  932. 

Halsted's  method,  919. 

Kocher's  method,  925. 

Lucas-Championniere's  method,  924. 

Mace  wen's  metiiod,  928. 
Hernia,  inguinal,  strangulated,  907. 
Hernia,  lateral,  ventral.  941. 
Hernia,  obturator,  strangulated,  913. 
Hernia  of  abdominal  wall,  898. 
Hernia  of  blaihler,  942. 
Hernia  of  diaphragm,  1035. 
Hernia  operations,  local  aiuesthesia  in,  942. 
Hernia,  retroperitoneal,  914. 
Hernia,  strangulateil.  899. 

herniotomy  for,  901. 

taxis  for  reduction  of,  899. 

washing  stomach  in,  905. 
Hernia,  umbilical,  ojieration  for  radical  cure 
of.  938. 

Boeckel's  method.  939. 

Dauriac's  transference  method,  939. 

Greig  .Smith's  method,  938. 

Qucnu's  method,  940. 

wire  gauze  support  in,  940. 
Hernia,  ventral,  operation  for  radical  cure 
of: 

Greig  Smith's  method,  940. 
Hernia,  ventral,  strangulated,  914. 
Herniotomy  for  strangulated  hernia,  901. 
Hilton's     method    of     amputating    penis. 

1223.  '  ^     ' 

"  Hockey-stick "  incision    (Meyer's)  for  re- 
moval of  appendix.  725. 
Howse's  method  of  fixing  stomach  in  gas- 
trostomy, 744. 
Howse's  operation  for  radical  cure  of  vari- 
cocele, 1231. 


Humjihrey's  method  of  amputating  penis, 

1223. 
Hydatids  of  tlie  liver,  796. 
Hydrocele  of  tunica  vaginalis  testis,  pallia- 
tive treatment  of,  1209. 
by  tapping.  1209. 
Hydrocele  of  tunica  vaginalis  testis,  radical 
treatment  of,  1211. 
by  excision  of  parietal  laver  (Von  Berg- 

mann),  1213. 
by  incision  (Volkmann),  1212. 
by  injection,  1211, 
by  partial  excision,  1213. 
Hydrogen   gas   in   detection    of    intestinal 

wounds,  667. 
Hypospadias,  1234. 
Anger's  operation  for  relief  of,  1236. 
Duplay's  operation  for  relief  of,  1236. 
Gouley's  operation  for  relief  of,  1235. 
Hypospadias,  perineal,  1244. 

Heo-cjecum,  resection  of  the,  706. 
Imperforate  rectum.  970. 
Incisions  for  removal  of  appendix  vermi- 
formis,  713. 

McBurney's  "gridiron,"  721. 

modified.  723.  725. 
Inguinal  hernia,  operations  for  radical  cure 
of.  915. 

Bassini's  method,  915. 

Bloodgood's    modification    of    Halsted's 
method,  922. 

Deaver's  method,  931, 

Fowler's  method,  932. 

Halsted's  method.  919. 

Kocher's  method,  925. 

Lucas-Championniere  method.  924. 

Macewen's  method,  928. 
Inguinal  hernia,  strangulated.  907. 
Injection    of   thvroid   for   relief   of  goitre, 

1094. 
Internal  urethrotomy.  1254. 
Intestinal  anastomosis.  624  et  seq. 
Intestinal  approximation  by  lateral  implan- 
tation, 648. 
Intestinal  approximation,  624. 

end-to-end,  bv  bone  bobbin  (Allingham), 
635. 

end-to-end,  by  bone  bobbin  (Hayes),  636, 

end-to-end,  by  bone  bobbin  (Robson),  635. 

end-to-end,  by  India-rubber  tube  (liobin- 
son),  636. 

end-to-end,  by  Lai)]ace's  method.  6.32. 

end-to-end,  by  [Maunsell's  method,  625. 

end-to-end,  by  Murphy's  method,  629. 

end-to-end.  of  unequal  segments,  637. 
Intestinal  approximation : 

lateral,  by  enterotome  (Grant).  648. 

lateral,  by  Laplace's  method,  634, 

lateral,  by  IMurphy's  button,  630. 

lateral,  by  potato  plates  (Dawbarn),  637. 

lateral,  by  Senn's  method.  637. 

lateral,  by  sewing  only  (Abbe),  644. 

lateral,  by  sewing  only  (Ilalsted),  645. 

lateral,   with    segmented    rubber    plates 
(Robinson),  643. 
Intestinal  obstruction,  abdominal  section  in, 
668,  670. 


INDEX. 


1295 


Intestinal  obstruction,  neoplasms  as  cause 

of.  TOU. 
Intestinal    perforation    in    tvphuid     fever, 

Intestinal  suture : 

Cusliiuj,''s,  O',*!. 

Czernv-Ijcuilpcrt.  021. 

Gely's,  ()'3(t. 

Gussenhauer's.  ()2'~. 

IlalsledV  (unit tress  or  quilt).  622. 

Joberl's.  ()22. 

Lenilu-rt's,  (!21. 

Senn's  uiodilU-atiou  of  Jobert's,  (52;}. 

Wollltr's,  ()22. 
Intestiiuil    suture,   continuous.   l)iii>uvtren, 

620. 
Intestinal  sutures,  619. 
Intestinal   wounds,  elbowing   in    repair   of, 

657,  i)()U. 
Intestinal  wouiuls,  hydrogen  gas  in  detec- 
tion of,  667. 
Intestinal  wouiuls,  repair  of,  653. 
Intestine,  contused  wounds  of,  668. 
Intestine,  distention  of,  in  treatment  of  in- 
tussusception, 6!)1.  692. 
Intestine,  injection  of  magnesium  sulphate 
into,  before  closing  abdomen  (McCosh), 
666. 

in  appetulicitis,  726. 
Intestine,  large,  gunshot  wounds  of,  667. 
Intestine,  lateral   anastomosis  of,  in  treat- 
ment of  intussusception,  695. 
Intestine,  snuill,  resection  of,  658. 

Ilalsted's  method.  662. 

Harris's  metiiod,  660. 

Koeher's  method.  659. 
Intestines,  operations  on  the,  618. 
Intubation  of  tiie  larynx  (()"I)wyer),  1071. 
Intussusception,  690. 

abdominal  section  in  treatment  of,  693. 

artificial  anus  in  treatment  of.  695. 

Barker's  operation  for,  696. 

Baracz's  operation  for,  698. 

distention   of   intestine   in   treatment  of, 
691.  692. 

lateral  anastomosis  in  treatment  of,  695. 

Mikulicz's  operation  for.  098. 

resection  with  enterorrhaphv  in  treatment 
of,  695. 
Ischio-rectal  abscess,  967. 

Jaboulay's  modification  of  gastro-enteros- 
tomy,  724. 

Jaboulay's  operation  of  exothyropexy.  1094. 

Jaboulay  aiul  Jonnesco's  excision  of  sympa- 
thetic for  relief  of  goitre.  1094. 

Jalaguier's  incision  for  removal  of  appen- 
dix vermiformis,  724. 

Jeannel's  operation  of  enteroplasty,  673. 

Jejunostomy,  766. 

Jobert's  intestinal  suture,  622. 

Jobeit's  intestinal  suture,  Senn's  modifica- 
tion of,  628. 

Joints,  movable  bodies  in.  1279. 

Kader's  operation  of  gastrostomy,  750. 
Kammerer's  incision  for  removal  of  appen- 
dix vermiformis,  724. 


Kappeler's  method  of  gastro-enterostomy, 
764. 

Keen's  opi-ration  of  complete  laryngectomy, 
10H2. 

Kelly's  method  of  catheterizing  ureter,  883. 

Keyijs's  method  of  circumcision,  1217. 

Keves's  operation  for  radical  cure  of  varico- 
■  cele,  1230. 

Kidneys,  operations  on,  824. 
puncture  of,  846. 
wounds  of,  >i47. 

Kleberg's  oi)eration  for  complete  i)rola[)se 
of  rectum,  979. 

Koeher's  einudeation-rescction  of  thvroifl 
body.  1091. 

Koeher's  iiu'ision  for  excision  of  breast,  1006. 

Koeher's  method  of  gastro-enterostomy,  759. 

Koeher's  method  of  performing  enterosto- 
my, 670. 

Koeher's  method  of  performing  partial  ex- 
cision of  thyroid  body,  1087. 

Koeher's  method  of  pylorectomy,  769. 

Koeher's  method  of  pylorectomy  combined 
with  gastro-enterostomy,  774. 

Koeher's  method  in  performing  complete 
laryngectomy,  1078. 

Koeher's  moditication  of  Ssabanejew- 
Franck's  method  of  gastrostomy,  748. 

Koeher's  operation  for  making  an  artificial 
anus,  672. 

Koeher's  operation  for  radical  cure  of  fem- 
oral hernia,  937. 

Koeher's  operation  for  radical  cure  of  in- 
guinal hernia.  925. 

Koeher's  operation  for  removal  of  naso- 
j)harvngeal  polypi  by  maxillary  route, 
587.  ' 

Koeher's  operation  for  resection  of  intes- 
tine, 649. 

Koeher's  operation  of  thyroidectomy,  1093. 

Koeher's  operation  in  sacral  proctectomy, 
991. 

Koeher's  treatment  of  goitre  by  ligature  of 
thyroid  arteries,  1094. 

Kraske's  operation  of  sacral  proctectomv, 
990. 

Kuster's  method  of  resecting  ureter  for 
stricture,  875. 

Lange's  operation  for  complete  prolapse  of 
rectum.  977. 

Langenbeck's  operation  for  removal  of  naso- 
pharyngeal polypi  by  maxillary  route, 
585.  " 

Langenbeck's  operation  for  removal  of  naso- 
pharyngeal polypi  by  nasal  route,  583. 

Laparotomy,  607. 
exploratory,  618. 

Laplace's  forceps  for  intestinal  approxima- 
tion, 631. 

Laplace's  operation  for  intestinal  anasto- 
mosis, end  to  end,  632. 

Laplace's  operation  for  intestinal  anasto- 
mosis, lateral.  634. 

Laryngectomy.  1078. 

Laryngectomy,  complete.  1078. 
Keen's  method.  1082. 
Koeher's  method,  1082. 


1296 


OPERATIVE  SURGERY. 


Larvngectomv,  complete,  Treves's  method, 

"1079. 
Laryngectomy,  partial.  1081. 
Laryngotomy,  1U68. 
Laryngo-tracheotomy.  1067. 

rapid  (Saint-Germain's).  1067. 
Larynx,  artificial  (Gussenbauer).  1086. 
Larynx,  intubation  of  (O'Dwyer).  1071. 
Lavage  of  stomach  in  strangulated  hernia, 

905. 
Lawrence's  operation  for  removal  of  naso- 
pharyngeal polypi  by  nasal  route,  583. 
Lemljert's  intestinal  suture.  6'21. 
Levy's  operation  in  sacral  proctectomy,  993. 
Ligature  of  bones,  1273. 
Ligature    of    bones  (frame)    for    fracture, 

1274 
Litholapaxy,  1165. 

Litholapaxy  and  evacuation  combined,  1172. 
Litholajmxy     and    evacuation,    Chismore's 

method.  1173. 
Litholapaxy  in  children.  1172. 
Litholapaxy  with  perineal  lithotrity,  1178. 
Lithotomy,"  1182. 

in  female,  1206. 

lateral,  1184. 

lateral,  in  children,  1188. 

median.  1192. 

medio-bilateral.  1196. 

suprapubic,  1196. 

suprapubic,  in  female,  1208. 
Lithotrity,  1160. 
Lithotrity  in  the  female.  1180. 
Lithotrity.  perineal,  with  litholapaxy,  1178. 
Lithotrity.  perineal,  with  litholapaxy,  Harri- 
son's method.  1179. 
Littre's  operation  for  iliac  colostomy,  675. 
Liver  abscess,  operation  for,  793. 

by  aspiration.  793. 

by  direct  incision,  793. 
Liver  cirrhosis,  operation   for   the  cure  of 

ascites  in.  802. 
Liver,  hydatids  of.  796. 

hepatectomy  for  relief  of,  797. 

hepatotomy  for  relief  of,  797. 
Liver,  operations  on,  791. 
Liver,  wounds  of.  800. 
Loreta's  operation  for  divulsion  of  pvlorus, 

779. 
Lowenstein's  modification  of  gastro-enter- 

ostomy.  758. 
Lowenstein's  operation  for  radical  cure  of 

femoral  hernia.  938. 
Lucas-Championniere's  operation  for  radical 

cure  of  inguinal  hernia,  938. 
Lung: 

abscess  of.  1039. 

gangrene  of,  1042. 

tuberculosis  of,  1044. 

tubercular  cavities  of,  1044. 

tubercular  deposits  in,  resection  of.  1045. 

tumor  of,  104^3. 
Lymphatic  glands,  removal,  1100. 

Martin's  method  of  implanting  ureter  into 

bowel,  862. 
Marwedel's  method  of  gastrostomy,  752. 
ilattress  suture  of  Halsted,  622. 


Maunseil's  operation  for  intestinal  approx- 
imation. 625. 

Maurv's  operation  for  relief  of  extroversion 
of  bladder,  1148. 

Maxillary  sinus,  o|)erations  on  the,  1281. 

Mavdl's  method  of  implanting  ureter  into 
'  bowel,  865. 

McBurney's  "gridiron"  incision  for  remov- 
ing appendix  vermiformis.  721. 

McBurney's  method  of  treating  stump  after 
removal  of  apiM-ndix  vermiformis,  714. 

"McBurney's  point."  708. 

McCosh's  method  of  treating  stump  after 
removal  of  appendix  vermiformis,  714. 

McCosh's  plan  for  injecting  magnesium  sul- 
phate into  bowel  before  closing  abdo- 
men. 066,  726. 

Macewen's  opei-alion  for  radical  cure  of  in- 
guinal hernia,  928. 

McGill's  operation  of  prostatectomy,  1135. 

McGuire's  method  of  making  artificial  ure- 
thra for  relief  of  prostatic  obstruction, 
1130. 

Mediastinal  thoracotomy,  1046. 
author's  method,  1046. 

Mesentery,  treatment  of,  after  resection,  664. 

Meyer's  "  hockey-stick "  incision  for  re- 
moval of  appendix  vermiformis,  725. 

Meyer's  operation  for  excision  of  breast, 
1013. 

Mikulicz's  operation  for  complete  prolapse 
of  rectum.  978. 

Mikulicz's  operation  for  intussusception,  698. 

Mikulicz's  operation  of  pharyngotomy,  577. 

Milton's  operation  of  anterior  thoracotomy, 
1052, 

Morris's  modification  of  McGuire's  method 
of  making  artificial  urethra  for  relief 
of  prostatic  obstruction.  1130. 

Morris's  operation  of  nephrolithotomy,  834. 

Morris's  operation  of  nephropexy,  830. 

Moynihan's  method  of  gastroplication,  783. 

Movable  bodies  in  joints,  1279. 

Murphy's  button  for  intestinal  anastomosis, 
629. 

Murphy's  button  in  entero-anastomosis,  765, 

Murphy's  button  in  gastro-enterostomy,  763. 
Weir's  modification.  766. 

Murphy's  button,  modified  for  use  in  chole- 
cystotomy,  811, 

Murphy  (J.  B.),  induction  of  pneumothorax 
for  cure  of  pulmonarv  tuberculosis, 
1046. 

Murphy's  operation  for  intestinal  approx- 
imation, end  to  end,  629, 

Murphy's  operation  for  intestinal  approx- 
imation, lateral,  630. 

Xailing  the  head  of  the  femur.  1276. 

Xares,  posterior,  plugging  of.  578. 

Nasal  polypi,  removal  of,  579. 

Xasal  septum,  operation  for   deviation   of, 

589, 
Naso-pharyngeal  polypi,  removal  of,  by  max- 
illary route.  585, 

Boeckel's  operation,  585. 

Cheever's  operation.  587. 

Guerin's  operation,  587. 


INDEX. 


1207 


Nftso-pharynpoal  polypi,  removal  of.  by 
niaxillaiy  itniti',  Kofher's  operation, 
OS  7. 

Laiiiri'iiliick's  opi-ratioii,  585. 
Naso- pi  laryngeal  polypi,  rotiioval   by  nasal 
routi'.'.jNl. 

Cliassaijjnac's  operation.  582. 

Lanm'nbi-ck's  opcratinii.  ."is;}. 

Lavvrc'iife's  (>|)eratic'K  5s:i. 

Ullier's  (ii>orali(>n,  o^O. 

Houj;i''s  opiTalion.  o!So. 
Na^o-pharyn^'oal  polypi,  removal  of,  by  pal- 
atine route,  584. 

Annanilale's  operation,  585. 

C'halot's  operation.  584. 

Nelaton's  operation.  584. 
Ncek.  operations  on  the,  1059. 
Xeerosis  of  rilis.  KCJl. 
Necrosis  of  sternum.  1032. 
Xelaton's  inethoil  of  repairing  epispadias, 

1240. 
Nelaton's  method  of  urethroplasty,  1246. 
Nelatou's  operation   for    removal  of   naso- 
pharvngeal    polvpi  bv   palatine   route, 
584.  ■ 
Nephrectomy.  841. 

abdominal,  843. 

extraperitoneal,  846. 

lumbar,  841. 

partial,  846. 
Nephrolithotomy.  834. 

Morris's  o|)eration,  837. 

the  abdominal  operation,  838. 
Nephropexy,  825. 

Franck's  method,  831. 

Morris's  method.  830. 

Senn's  method.  829. 

Tuffier's  method.  831. 

Vulliet's  method.  831. 
Nephrorrhaphv.  825. 
Nephrotomy,  839. 
Nerve,  cervical  svmpathetic,  operations  on, 

1282. 
Nose,  operations  on,  578. 

Obstruction,  intestinal,  abdominal  section 
in.  688,  670. 

Obstruction,  intestinal,  neoplasms  as  cause 
of.  700. 

Obturator  hernia,  strangulated,  913. 

O'Dwver's  operation  for  intubation  of  lar- 
ynx. 1071. 

fEsophagectomy,  606. 

(l%sophas;ostomy.  606. 

(Esophagotoiny,  596. 
cervical.  596. 

CEsopliagotomv  for  removal  of  foreign  bod- 
ies, 596. 

CEsophagotomy.  internal,  for  stricture.  602. 

Oesophagus,  introduction  of  instruments 
into.  ,593. 

Qilsophagus.  introduction  of  stomach  tube 
through,  593. 

CEsophagus,  operations  on  the,  591. 

(Esophagus,  removal  of  foreign  bodies  from, 
591. 

CEsophagus.  removal  of  foreign  bodies  from, 
by  gastrotomy,  599. 


(Esophagus,  removal  of  f<preign  bodies  from, 

by  (I'sopiiagoioiiiy.  5!M!. 
(Esopliagus.  stricture  of  the.  600. 

direct  dilatation  for,  600. 

direct  (livulsion  for.  602. 

division  liv  means  of  string  friction  for, 
603. 

division  by  si  ring  friction  for  (Abbe),  603. 

division   1)V  string   friction   for  (author), 
604. 

external  division  for,  596. 

internal  division  for.  (502. 

retrograde  dilatation  for,  602. 

retrograde  divulsion  for,  6(J2. 

tubage  for.  605. 
Olecranon  process,  fracture  of,  suture  for, 

1271. 
Ollier's  operation  for  removal  of  naso-phar- 

yngeal  jiolypi  by  nasal  route,  582. 
Omental  grafting.  074. 
Operations  for  radical  cure  of  feraoral  her- 
nia. 936. 

Bassini's  method.  936. 

Bottini's  method.  938. 

Coley's  nietliod.  937. 

Gordon's  method,  938. 

Kocher's  method.  937. 

Lowenstein's  method,  938. 

Trendelenburg's  method,  938. 
Operations  for  radical  cure  of  hernia,  915. 
Operations  for  railical  cure  of  inguinal  her- 
nia. 915. 

Bassini's  method.  915. 

Bloodgood's    modification    of     Ilalsted's 
method.  919. 

Deaver's  method,  931, 

Fowler's  method,  932. 

Halsted's  method,  919. 

Kocher's  method.  925. 

Lucas-Chami)ionniere's  method,  924. 

Macewen's  method.  928. 
Operations  on  anus  and  rectum.  946  ef  seq. 
Operations  on  heart  and  pericardium.  1034. 
Operations  on  the  neck,  1059. 
Operations  on  the  scrotum  and  penis,  1209 

et  seq. 
Operations  on  the  tongue.  565. 
Operations  on  the  thyroid  body.  1086. 
Operations  on  the  urinarv  bladder,  1108. 
Orchidopexy,  1216. 

Pancreas,  operations  on,  891. 

Pancreatic  cyst,  operation  for,  892. 

Paracentesis  abdominis,  895. 

Paraphimosis,  1220. 

Parkhill's    method    of    uniting    fractured 

bones.  1276. 
Parotid  gland,  extirpation  of,  1105. 
Patella,  fracture  of: 

Barker's  method  of  treatment.  1266. 

Ceci's  method  of  treatment,  1268. 

.Stimson's  method  of  treatment,  1266. 
Patella,  fracture  of,  suture  for,  1260. 

by  oval  incision,  1262. 

by  transverse  incision,  1262. 

bv  vertical  incision.  1262. 
Patella,  old  fracture  of.  1268. 
Paul's  operation  of  colectomy,  703. 


1298 


OPERATIVE  SURGERY. 


Pc^j^'iiijif  of  1)0110  for  relief  of  frtieture,  1274. 

intriiiiic(lullary,  1274. 
Penis,  uiiiimtiilion  of.  1222. 

iin  old  method,  1223. 

Davies-Colly  method,  1224. 

flap  method,  1223. 

lliitoirs  method,  1223. 

Ilmnphrey's  method.  1223. 

Tiiierseh's  metiiod,  1224. 
Penis,  extirpation  of,  1225. 

Gould's  method,  1225. 

Gouley's  metliod,  1226. 
Penis,  operations  on  the,  1209. 
Pericardium,  asj)iration  of,  1055. 
Pericardium,  operations  on,  1054. 
Pericardiotomy,  1057. 
Perforation,    intestinal,    in    tyj)hoid    fever, 

728. 
Perineal  hypospadias,  1244. 
Perineal  section  (Gouley),  1249. 
Perineal  urethroplasty,  1247. 
Perineal     urethrotomy,  external    (Gouley), 
1249. 

with  a  guide,  1249. 
Peritoneal  adhesions,  management  of,  607. 
Peritoneal  cavity,  cleansing  of.  612. 
Peritoneal  cavity,  drainage  of,  613. 
Peritonitis,  tubercular,  730. 
Peters's  o[)eration  for  complete  prolapse  of 

rectum  (proctopexy),  982. 
Pharyngotomy,  576. 

Cheever's  method,  576. 

Czerny's  method,  577. 

Mikulicz's  meth(jil,  577. 
Pharyngotomy,  subhyoid,  1070. 
Phelps's  wire  filigree  support  in  operation 

for  umbilical  hernia,  940. 
Phlegmon  of  tlie  neck,  1098. 
Pleural  cavity,  aspiration   and  drainage  of, 

1026. 
Plugging  the  posterior  nares,  578. 
Pneumothorax  induced  in  cure  of  pulmo- 
nary tuberculosis  (Murphy),  1046. 
Pollock's  operation  for  cure  of  hiemorriioids, 

960. 
Polypi,  nasal,  removal  of,  579, 
Polypi,    naso-pliaryngeal,     removal    of,    by 
maxillary  route,  585. 

Boeckel's  operation,  585. 

Cheever's  operation,  587. 

Guerin's  operation,  587. 

Kociier's  operation,  587. 

Langenbeck's  operation,  585. 
Polypi,   naso-pharyngeal,     removal    of,    by 
nasal  route,  581. 

Chassaignac's  operation,  582. 

Langenbeck's  operation,  583. 

Lawrence's  operation,  583. 

Ollier's  operation,  582. 

Rouge's  operation,  583. 
Polypi,    naso-pharyngeal.     removal   of,   by 
palatine  route.  584. 

Annandale's  operation,  585. 

Chalot's  operation.  584. 

Nelaton's  operation,  584. 
Poncet's  urethrostomy,  1247. 
Potato  plates  in    intestinal    approximation 
(Dawbarn),  641. 


Pousson's  operation    for   cure  of  extrover- 
sion of  bladder,  1153. 
Proctectomy,  988. 

Proctectomy,  perineal  (AUiiigham),  988. 
Proctectomy,  sacral,  990. 

Borelius's  operation,  99.3. 

Ileineke's  operation,  991. 

Kocher's  operation,  991. 

Kraske's  operation,  990. 

Levy's  operation,  993. 

Tuttle's  operation,  992. 

Rehn-Rydygier's  operation,  993. 
Proctectomy,  vaginal,  1002. 
Proctectoinv,  vicarious  sphincteric,  control 
after,  995. 

Gersuny's  method,  996. 

Willem's  method,  996. 
Proctopexy : 

Peters's  method,  979. 

Tuttle's  method,  980. 

Verneuil's  method,  979. 
Proctoplasty  for  relief  of  imperforate  rec- 
tum, 972. 

Rizzoli's  method,  973. 
Proctorrhaphy.  Lange's  method,  977. 
Proctotomy,  external,  987. 
Proctotomy,  internal,  984. 

Bacon's  method,  984. 

Ilartmann's  method,  987. 
Proctotomy,  linear  or  posterior,  987. 
Prolapsus  recti,  974. 

cauterization  of  (Van  Bureii),  975. 

partial,  974. 

treatment  of,  974. 
Prolapsus  recti,  complete,  976. 

Kleberg's  operation  for  relief  of,  979. 

Lange's  operation  for  relief  of  (proctor- 
rhaphy), 977. 

Mikulicz's  operation  for  relief  of,  978. 

Peters's   operation  for  relief  of  (procto- 
pexy), 978. 

Roberts's  operation  for  relief  of,  977. 

Treves's  opei'ation  for  relief  of,  978. 

Tuttle's   operation  for   relief  of   (procto- 
pexy), 980. 

Verneuil's  oi)eration  for  relief  of  (procto- 
pexy), 979. 
Prostate,  enlarged,  as  cause  of  retention  of 

urine,  1114. 
Prostate,  hypertrophy  of,  1142. 

galvano-cautery  method,  for  relief  of  (Bot- 
tini),  1143. 

ligature  of  internal  iliac  arteries  for  relief 
of  (Bier),  1143. 

vasectomy  for  relief  of  (Albarran),  1142. 
Prostatectomy,  1131. 

combined  method  (Alexander),  1137. 

combined  method  (Belfield),  1135. 

lateral  (Dittel's),  1135. 

perineal,  1134. 

suprapubic  (McGill),  1132. 
Prostatic  abscess,  1144. 

Dittel  and  Zuckerkandl's  operation  for  re- 
lief of.  1144. 
Prostatic  obstruction,  artificial  urethra  for 

relief  of,  1129. 
Prostatic  obstruction.  McGuire's  method  of 
making  artificial  urethra,  1130. 


INDEX. 


1 2')9 


Prostatic  otistniotioii,  Mftiiiirc's  inctliod  of  ' 
iiiakiMf^arliliciiil  urctlira.  Morris's  iiiodi- 
lication  of,  1  lot). 
Psoas  al)si't'ss,  12oS. 
Pyloivc'toiny,  7GS. 

KorliiM-'s  iin'tiiod,  7()!(. 
Pyloroi'toiiiy  coiMliiiit'ii  with  gastro-eiiteros- 
toiny.  77:5. 

Czcrny's  iiiodiliration,  774. 

Koc'Iut's  inodilicatioii,  774. 
Pyloro])lasty,  777. 

"(iiviic-Smi til's  tiiodific-ation.  779. 

IIeiiu'l<('-Mii<ulifz"s  motliod,  777. 
Pylorus,  diviilsion  of,  77!*. 

Ijori'ta's  operation,  779. 
PuiR'tiiro  of  tlic  bladder,  1115. 

by  direet  incision,  lllo. 

by  suprapubic  route.  111."). 

through  the  rei-tuni,  1116. 

under  the  pubes.  IIIG. 

with  a  trocar,  1115. 

Quadriceps  extensor  fenioris,  rupture  of 
tendon  of,  1270. 

Qucnu's  operation  for  radical  cure  of  um- 
bilical hernia,  940. 

Ranula.  575. 

Reclus's  operation  of  iliac  colostomy,  681. 

Rectum,  anatomy  of,  963, 

examination  of,  965. 

operations  on  the,  963  et  seq. 
Rectum,  imperforate,  970. 

operation  for  relief  of,  972. 

proctoplasty  for  relief  of,  972. 

proctoplasty  for  relief  of  (Kizzoli's  meth- 
od), 973.  ■ 
Rectum,  introduction  of  bougies  into,  983. 
Rectum,  prolapse  of.  974. 
Rectum,  jirolapse  of,  complete,  876. 

Klel)erg's  operation  for  relief  of.  978. 

Lange's  operation  for  relief  of,  977. 

Mikulicz's  operation  for  relief  of.  978. 

Peters's  operation  for  relief  of,  982. 

Roberts's  operation  for  relief  of,  977. 

Treves's  operation  for  relief  of.  978. 

Tuttle's  operation  for  relief  of,  980. 

Verneuil's  operation  for  relief  of,  979. 
Rectum,  prolapse  of,  partial.  974. 

cauterization  for  relief  of  (Van  Bnren), 
975. 
Rehn-Rvdvgier's  operation  in  sacral  proc- 

tectoniy,  993. 
Resection  of  small  intestines.  658. 

Halsted's  method.  659. 

Kocher's  method.  (i62. 
Resection  of  the  imrder  of  the  thorax.  823. 
Resection  of  thyroid  body  (Kocher),  1093. 
Respiration,  artificial.  Fcll-O'Dsvyer's  appa- 
ratus for  inducing.  1033. 
Retention  of  urine.  1112. 

from  ehlarged  prostate.  1114. 

from  stricture.  1112. 
Retroperitoneal  hernia.  914. 
Retropharyngeal  abscess.  1099. 

Buclchardt's  operation  for,  1100. 

Chiene's  operation  for.  1099. 
Ribs,  caries  and  necrosis  of,  1031. 
88 


Kills,  excision  of.  in  thoracotomy,  1023. 
Delorme's  operation,  1030. 
Ksllilnder's  operation.  1029. 
Feiiger's  opi'iation.  1030. 
Sciinle's  operation,  H)29. 
Ribs,  tumors  of,  1032. 

Richardson's   operation    for   complete    gas- 
trectomy. 790. 
Richelot's  operation  for  salivary  fistula.  564. 
Ricord's  oiieration  for  radical  cure  of  vari- 
cocele, 1230. 
Rigaud's  method  of  urethroplasty,  1246. 
Rizzoli's  method  of  [iroctoplasty  for  relief 

of  imperforate  rectum,  973. 
Roberts's  operation  for  complete  prolapse  of 

rectum,  977. 
Robinson's  method  of  intestinal  anastomosis 

by  rubber  tube,  636. 
Robinson's  method  of  intestinal  anastomosis 

by  segmented  rubber  plates.  643. 
Robson's  bone  bobbin  for  intestinal  approxi- 
mation, 635. 
Robson's  modification  of  Wood's  operation 

for  extroversion  of  the  bladder,  1150. 
Rouge's  operation  of  removal  of  naso-pha- 

ryngeal  polypi  by  nasal  route,  583. 
Roux's  method  of  gastro-enterostomy.  763. 
Rupture  of  the  bladder,  1117. 
extraperitoneal,  1117. 
intraperitoneal.  1117. 
Rupture  of  the  urethra,  1253. 
operation  for  rejiair  of,  1253. 

Salivary  fistula,  operations  for  relief  of,  563. 

Agnew's  method,  563. 

Dequise's  method,  564. 

Desault's  method,  563. 

Richelot's  method,  564. 

Van  Buren's  method,  564. 
Schede's    operation    for    relief   of    chronic 

empyenui,  1029. 
Schlatter's  operation  for  complete  gastrec- 
tomy, 788. 
Schleich's  infiltration  anaesthesia  in  opera- 
tions on  hernia,  942. 
Scrotum  : 

elephantiasis  of.  1232. 

excision  of.  for  relief  of  varicocele,  1237. 

operations  on  the.  1209. 
Section,  abdominal,  607. 

explorative,  618. 

for  penetrating  gunshot  wounds.  650. 

for  wounds  of  abdominal  viscera.  650. 

in  intestinal  obstruction.  670.  688. 

in  treatment  of  intussuseeption.  693. 
Segond's  modification  of  Thiersch's  opera- 
tion for  extroversion  of  bladder,  1153. 
Senn's  incision  for  excision  of  breast,  1006. 
Senn's   method    of    intestinal    anastomosis 

(lateral).  637. 
Senn's   modification   of  Jobcrt's   intestinal 

suture,  623. 
Senn's  (K.  T.),  operation  of  gastrostomy,  749. 
Senn's  operation  of  nephropexy,  839. 
Senn's  plates  for  intestinal  anastomosis,  637. 
Septum  nasi,  deviation  of  the.  589. 
Sinus,  frontal,  operations  on,  1280. 
Sinus,  maxillary,  operations  on,  1281. 


1300 


OPERATIVE  SURGERY. 


Smith's  (Greig)  operation  for   extroversion 

of  bladder,  1152. 
Soein's  method  of  enucleating  the  thyroid 

body,  1092. 
Sonnenberg"s  method  of  gaslro-enterostomy, 

761. 
Sounds,  care  of,  1108. 

introduction  into  bladder  of,  1109. 
Sphincteric  control,  vicarious,  after  artificial 

anus,  996. 
Sphincteric    control,  vicarious,  after  proc- 
tectomy, 995. 

Gersuny's  method.  996. 

Willem's  method,  996. 
Spleen,  aspiration  of,  891. 

operations  on.  888. 
Splenectomy,  888. 
Splenopexy,  890. 
Splenotomy,  891. 

Ssabanejew-Franck's  oijeration  of  gastros- 
tomy. 748. 
Stab  wounds  of  abdomen,  667. 
Stamm"s  method  of  gastrostomy,  752. 
Sternum  : 

caries  of,  1031. 

necrosis  of,  1031. 

tumors  of,  1032. 
Saint-Germain's  operation  for  laryngo-tra- 

cheotomy,  1067. 
Stimson's  method  of  treating  fractured  pa- 
tella, 1266. 
Stomach  : 

dilatation  of  cardiac  orifice  of,  780. 

method  of  fixation  in  gastrostomy  (Howse), 
744. 

operations  on,  737. 

wounds  of,  790. 
Stomach  tube,  introduction  of,  593. 
Stone  in  bladder,  1156. 
Strangulated  hernia.  899. 

herniotomy  for.  901. 

taxis  for  reduction  of.  899. 

washing  stomach  in.  905. 
Strangulated  femoral  hernia,  909. 

taxis  in,  910. 
Strangulated  inguinal  hernia.  907. 
Strangulated  obturator  hernia.  913. 
Strangulated  umbilical  hernia,  912. 
Strangulated  ventral  hernia,  914. 
Stricture  of  a?sophagus,  operations  for,  600. 

Abbe's  method.  603. 

author's  method.  604. 
Stricture  of  urethra   as  cause  of  retention 

of  urine,  1112. 
Subphrenic  abscess.  893. 

abdominal  incision  for.  893. 

thoracic  incision  for,  894. 
Suprapubic  cystotomy,  1115. 
Suture,  intestinal,  continuous  (Dupuytren), 

620. 
Sutures,  intestinal : 

Cushing's,  621. 

Czernv-Lembert,  621. 

Gely's.  620. 

Gussenbauer's,  622. 

Halsted's  (mattress  or  quilt),  622. 

Jobert's.  622. 

Jobert-Senn's  modification,  623. 


Sutures,  intestinal,  Lembert's,  621. 

Wo) tier's.  622. 
Sympathetic  nerve,  cervical,  operations  on, 

1282. 
Sympathetic  nerve,  excision  of,  for  relief  of 

goitre,  1094. 
Szymanowski's  method  of  repairing  urethral 

fistula,  1238. 

Tamponing  of  the  trachea,  1084. 
Tapping  of  hydrocele,  1209. 
Tapping  of  the  urethra  (Cock),  1257. 
Taxis  for  reduction  of  strangulated  hernia, 

899. 
Testicle,  removal  of,  1214. 
Testicle,  undescended,  operation  for  relief 

of,  1216. 
Thiersch's   method   of    amputating    penis, 

1224. 
Thiersch's  method  of  repairing  epispadias, 

1241. 
Thiersch's  operation  for  extroversion  of  blad- 
der. 1152. 
Thomas's  method  of  excision  of  non-malig- 
nant tumors  of  breast,  1020. 
Thoracentesis,  1020. 
Thoracoplasty : 

Delorme's  operation,  1030. 

Estlander's  operation.  1029. 

Fenger's  operation,  1030. 

Schede's  operation,  1029. 
Thoracotomy.  1023. 

by  simple  incision,  1024. 

with  excision  of  a  rib.  1023. 
Thoracotomy,  mediastinal,  1046. 

anterior  (Milton).  1052. 

author's  method,  1046. 
Thorax,  aspiration  of,  combined  with  drain- 
age of  pleural  cavities  (author's  method), 
1026. 
Thvroid  arteries,  ligature  of,  for  relief  of 

"  goitre.  1094. 
Thyroid  bodies,  operations  on,  1086. 

partial  excision  of  (Kocher),  1087. 

partial  excision  of,   bv  angular  incision, 
1088. 
Thyroid  body,  enucleation  of  (Socin),  1092. 

enucleation — resection  of  (Kocher),  1091. 
Thyroidectomy.  1093. 
Thyrotomy,  1()67. 

Tongue,  excision  of.  by  V-shaped  incision, 
566. 

entire,  569. 

instruments  for.  567. 

Koeher's  method,  570. 

one  half  of,  568. 

through  the  mouth.  569. 
Tongue,  excision  of,  with  division  of  jaw, 
571. 

Baker's  operation.  572. 

Billroth's  operation.  573. 

Jaeger's  operation.  572. 

Langenbeck's  oj)eration,  573. 

Kegnoli's  operation,  573. 

Sedillot's  opej-ation,  571. 
Tongue,  hypertrophy  of,  568. 
Tongue,  operations  on,  565. 
Tongue-tie,  575. 


INDEX. 


v.ioi 


Tonsil,  !il)scess  of,  565. 
excision  of,  504. 

roiiioviil  of  tumor  of,  with  |)illur  of  fiiuces, 
575. 
Traehoa,  tainpoiiinu;  of,  1084. 
Tracheotomy,   l(J(i5. 
above  isthmus,  1006. 
below  istiiinus,  1065. 
Transverse  colon,  operations  on  the,  700. 
Treves's  oi)enilion  for  complete  prolapse  of 

rectum,  978. 
Treves's     operation     of     complete     laryn- 
gectomy, 1079. 
Trendelenbiiri^'s  method  of  approximating 
innominate  bones  for  extroversion    of 
bladder,  1154. 
Trendelenburg's  operation  for  radical  cure 

of  femoral  hernia,  9;:}8. 
Tubercular  cavities  in  lung,  1044. 
Tubercular  deposits   in  lung,  resection  of, 

1045. 
Tubercular  peritonitis,  ~'-iO. 
Tuberculosis  of  lung,  1044. 
TufRer's  operation  of  nephropexy,  831. 
Tuffier's   method  of   uretero-iireteral   anas- 
tomosis, 854. 
Tumors  of  breast,  non-nuilignant,  excision 

of,  1020. 
Tumors  of  lung.  1043. 
Tumors  of  ribs,  1033. 
Tumors  of  sternum,  1033. 
Tunica  vaginalis  testis,  hydrocele  of,  1209. 
palliative  treatment  of,  1209. 
radical  treatment  of,  by  excision,  parietal 

layer  (Bergmann),  1313. 
radical  treatment   of,  by  incision  (Volk- 

mann).  1213. 
radical  treatment  of,  by  injection,  1311. 
radical  treatment  of,  by  partial  excision, 
1213. 
Tuttle's  operation  for  complete  prolapse  of 

rectum  (proctopexy),  980. 
Tuttle's  operation  in  sacral  i)roctectomy,992. 

Ulcer,  gastric,  784. 

operation  for  control  of  haemorrhage  in, 
787. 

operation  for  non-perforating,  786. 

operation  for  perforating,  784. 
Umbilical    hernia,  operations    for    radical 
cure  of : 

Boeckel's  method,  993. 

Dauriac's  transference,  999. 

Greig  Smith's  method,  938. 

Quenu's  method,  940. 

Wire  gauze  support  in,  940. 
Ureter,  catheterization  of,  883. 

Harris's  method,  883. 

Kelly's  method,  886. 
Ureterectomy,  868. 
Ureter,  implantation  of.  859. 
Ureter,  implantation  of,  into  bladder,  859. 

extraperitoneal  method  (Raumm's),  859. 

extraperitoneal  method  (Witzel's),  860. 

intraperitoneal  method,  860. 
Ureter,  implantation  of,  into  bowel,  863. 

C"ha|)ut's  method,  863. 

Fowler's  method,  863. 


Ureter,  implantation  of,  into  bowel,  Martin's 
mclliod,  H()'^>. 

Maydl's  method,  865. 
Ureter,  implantation  of,  into  vagina,  866. 
Ureter,  implantation  of,  on  the  skin,  866. 
Ureter,  operations  on  the,  850. 
Ureter,  stricture  of,  873. 

Alsberg's  operation  for  relief  of,  873. 

Fenger's  o[)eration  fur  relief  of.  873. 
Ureter,  stricture,  resection  for,  875. 

Kiister's  metliod,  875. 
Ureter,  valve  formation  in,  relief  of,  870. 

Fenger's  operation  for,  871. 
Ureter,  wounds  of,  853. 
Ureterotomy,  867. 

extraperitoneal,  867. 

transperitoneal.  867. 
Urethra,  congenital  malformations  of,  1234. 
Urethra,  foreign  bodies  in,  1203. 
Urethra,  rujiture  of.  1253. 

operation  for  relief  of,  1253. 
Urethra,  tapping  of  (Cock),  1257. 
Urethral  defects,  acquired,  1244. 
Urethral  fistula.  Szymanowski's  method  of 

repairing,  1238. 
Urethral  stricture  as  cause  of  retention  of 

urine,  1112. 
Urethroplasty,  1245. 

by  flap  transplantation.  1247. 

Delpech's  method,  1246. 

Dieffenbach's  method,  1246. 

Dittel's  method  (bv  fla[)  sliding),  1346. 

Nelaton's  method,"  1246. 

Rigaud's  method,  1246. 
Urethroplastv,  perineal,  1247. 
Urethrorrhaphv,  1244. 
Urethrostomy  (Poncet),  1347. 
Urethrotomy,   external    perineal  (Gouley), 
1349. 

with  a  guide,  1249. 
Urethrotomv,  external,   without    a    guide, 

1251. 
Urethrotomy,  internal,  1254. 
Ureteral  calculus,  867. 
Uretero-cystostomy,  959. 
Uretero-urethral  anastomosis,  866. 
Uretero-ureteral  anastomosis,  854. 

by  invagination.  855. 

by  lateral  implantation  (Emmet),  857. 

by  lateral  implantation  (Van  Hook),  856. 

oblique  end-to-end  method  (Bovee),  854. 

transverse   end-to-end    method    (Tufiier), 
854. 
Urine,  retention  of,  1113. 

from  enlarged  prostate,  1114. 

from  stricture,  1113. 

Vaginal  proctectomy,  1003. 

Van  Buren's  cauterization  method  for  treat- 
ing partial  prolapse  of  rectum,  975. 

Van  Buren's  operation  for  salivary  fistula, 
564. 

Van  Hook's  method  of  uretero-ureteral  anas- 
tomosis. 856. 

Varicocele,  1337. 

Varicocele,  excision  of  scrotum  for  relief  of, 
1237. 

Varicocele,  palliative  treatment  of,  1327. 


1302 


OPERATIVE   SURGERY. 


Varicocele,  radical  treatment  of.  1228. 
Bennett's  modification  of  Howse's  method, 

1231. 
by  free  incision  with  excision  of  veins 

(Howse),  1231. 
by  subcutaneous  ligature  (Keyes),  1230. 
compression  by  pins,  1229. 
compression  by  wire  (Eriehsen).  1229. 
compression  by  wire  (Videl).  1229. 
double-loop  compression  of  Kicord,  1230. 
Vas  deferens,  repair  of.  1232. 
Vaseetouiy,  for  relief  of  prostatic  hypertro- 
phy (Albarran),  1142. 
Ventral  hernia,  lateral,  941. 
Ventral  hernia,  radical  cure  of,  940. 

Greig  Smith's  operation,  940. 
Ventral  hernia,  sirangulated,  914. 
Vermiform  appendix: 

Dawbarn's  method  of  treating  stump,  714. 
Fowler's  method  of  treating  stump,  714, 

715. 
McBurney's  method  of  treating  stump, 

714. 
McCosh's  method  of  treating  stump,  714. 
Vermiform  appendix,  incisions  for  removal 
of,  713. 
Battle's,  724. 
Elliot's.  723. 
Fowler's,  725. 
Jalaguier's,  724. 
Kammerer's,  724. 
McBurney's  "gridiron,"  721. 
Meyer's  "  hockey-stick,"  725. 
modified,  723. 
Vischer's,  725. 
Weir's.  723. 
Vermiform  appendix,  removal  of,  708. 
Vermiform   appendix,  removal   of,  during 

interval,  723. 
Verneuil's  operation  for  complete  prolapse 

of  rectum  (proctopexy),  979. 
Videl's  operation  for  radical  cure  of  varico- 
cele. 1229. 
Vischer's  incision  for  removal  of  appendix 

vermiformis.  724. 
Volkmann's  operation   for  radical   cure  of 
hydrocele,  1212. 


Volvulus,  699. 

Von  Bergmann's  operation  for  radical  cure 

of  hydrocele,  1213. 
Von  Hacker's  incision  for  gastrostomy,  746. 
Von   Hacker's  method  of  gastro-enterosto- 

my,  761. 
Vulliet's  operation  of  nephropexy,  831. 

Warren's  incision  for  excision  of  breast, 
1006. 

Watson's  method  of  gastro-enterostomv, 
.  .'81. 

Weir's  incision  for  removal  of  appendix 
vermiformis,  723. 

Weir's  ujcthod  of  gastroplication,  783. 

Weir's  modification  of  Murphy's  button  in 
gastro-enterostomy,  766. 

Whitehead's  operation  for  cure  of  haemor- 
rhoids, 959. 

Willem's  method  for  vicarious  sphincteric 
control  after  proctectomy,  996. 

Wiring  of  fractured  bones.  1272. 

Witzel's  extraperitoneal  method  of  implant- 
ing ureter  into  bladder.  860. 

Witzel's  operation  of  gastrostomy,  746. 

Wolfler's  intestinal  suture,  622. 

Wolfler's  method  of  gastro-enterostomy, 
781. 

Wolfler's  modification  of  gastro-enteros- 
tomy, 781. 

Wood's  operation  for  extroversion  of  blad- 
der, 1149. 

Wounds,  contused,  of  abdomen.  608. 

Wounds,  contused,  of  intestine.  668. 

Wounds,  gunshot,  of  duodenum.  667. 

Wounds,  intestinal,  elbowing  in  repair  of, 
657,  669. 

Wounds,  intestinal,  repair  of,  653. 

Wounds,  intestinal,  use  of  hydrogen  gas  in 
detection  of.  667. 

Wounds  of  abdominal  A-iscera,  abdominal 
section  for.  650. 

Wounds  of  diaphragm.  1035. 

Wounds  of  large  intestine.  667. 

Wounds,  penetrating,  of  abdomen,  abdom- 
inal section  for,  650. 

Wounds,  stab,  of  abdomen,  667. 


THE   EXD. 


THE  DISEASES  OF  THE 
STOMACH. 

By    Dr.    C.    A.    EWALD, 

KXTUAi'lJOlNAKV    I'ltDKKSSi  iK    OK    M  KDKJI.N  K    AT    TIIK    UNI  VKKSITY    OR    BKRLIX. 

SfCDild  Aineiican   Edition,  franshited  and  edited,  with  niiineronn  Additions, 
from  till-   T/iird  Gei-man  Edition, 

By   MORRIS    MANGES,   A.  M.,   M.  D., 

ASSISTANT     VISITINd     I'll  VSICl  AX    TO    MOINT    SINAI     IIOSIMTAL;     I-KCTIKKU    OS 
UKNEKAL    MEUICINK,    NEW     YOKK     I'OL YCLIMC,    ET(  . 

This  work   has  been  thoroughly  revised,   rearranged,   largely   rewritten,  and 
brought  up  to  date  from  the  most  recent  literature  on  the  subject. 


8vo,  602  pages.     Sold  by  subscription.     Cloth,  $5.00 ;  sheep,  $6.00. 


"In  giving  the  medical  j^rofession  this  second  revised  translation  of  Prof. 
Ewald's  treatise  on  the  Diseases  of  the  Stomach,  Dr.  Manges  has  placed  the  profes- 
sion  under  even  greater  obligations  than  we  owed  for  the  first.  The  first  transla- 
tion was  then  an  almost  exhaustive  treatise,  and  now,  with  so  much  new  and 
valuable  data  added,  the  work  is  a  sme  qua  non." — Atlanta  31edical  and  Surgical 
Journal. 

'■  This  work  as  it  now  stands  is  the  best  on  the  subject  of  stomach  diseases  in 
the  English  language.  No  physician's  library  is  complete  without  it.  It  is  in 
every  way  well  adapted  to  the  requirements  of  the  general  practitioner,  although 
complete  enough  to  meet  also  the  requirements  of  the  specialist." — American 
Medico- Surgical  Bulletin. 

"  The  present  American  edition  is  a  peculiarly  valuable  one,  as  the  editor. 
Dr.  Manges,  has  done  his  work  in  a  thoroughly  creditable  manner.  His  numer- 
ous notes,  additions,  and  new  illustrations  have  made  the  book  a  classic  one. 
Under  these  circumstances  it  should  find  a  place  in  the  library  of  every  Amer- 
ican physician,  as  their  clientele  is  composed  of  such  a  large  proportion  of  patients 
suffering  from  gastric  complaints  and  more  or  less  improper  medication  which 
most  often  ends  in  failure.  There  is  no  doubt  that  more  properly  directed  efforts 
in  the  proper  direction,  as  outlined  in  Ewald's  book,  would  soon  remove  from 
Americans  the  reputation  of  being  a  nation  of  dyspeptics." — St.  Louis  Medical 
and  Surgical  Journal. 

"Dr.  Ewald's  book  has  met  with  a  very  cordial  reception  by  the  medical  pro- 
fession. Within  a  short  period  three  editions  have  appeared,  and  translations 
published  in  England.  Spain,  France,  Italy,  and  the  United  States.  To  the 
present  edition  the  author  has  not  only  added  considerable  new  matter,  but  he 
has  also  entirely  rewritten  the  work.  The  arrangement  of  the  chapters  has  been 
somewhat  changed,  and  many  new  personal  observations  and  therapeutic  experi- 
ences added.  The  desirability  of  surgical  interference  is  carefully  considered,  and 
the  pros  and  cons  given  so  far  as  would  be  necessary  to  enable  a  physician  to 
determine  whether  the  aid  of  the  surgeon  might  be  required.  The  translator  has 
done  his  work  well,  and  has  incorporated  nnich  new  matter  into  the  text  and 
footnotes." — Xorth  American  Journal  of  Homoeopathy. 


D.  APPLETON  AND  COMPANY,  NEW  YORK. 


A  PRACTICAL  TEEATISE  ON  THE 

SURGICAL  DISEASES 

OF  THE  GENITO-LJRINARY 

ORGANS, 

INCLUDING  SYPHILIS. 

DESIGXED  AS  A  MANUAL  FOR  STUDENTS  AND  PRACTITIOXERS. 

With  Engravintjs. 

By  E.  L.  KEYES,  A.  M.,  U  D., 

Professor  of  Genito-Urinary  Surgery,  Sypliilology,  and  Cerinatology 
in  Bellevue  Hospital  Medical  College. 

BEIXG  A  EEVISIOy  OF  A   TREATISE,  BEARIXG   THE  SAME   TITLE,  B7 
VAN  BUREX  AND  KEYES. 

SECOND    EDITIOX,    THOROUGHLY   REVISED,   AND   SOMEWHAT   ENLARGED. 


8vo.    68S  pages.    Cloth,  $5.00 ;  sheep,  $6.00. 


"  The  progress  made  in  surgery  during  the  last  ten  years,  the  changes  of  practice  by  the 
best  surgeons  with  regard  to  several  operative  procedures,  notably  litholapaxy,  suprapubic 
cystotomy,  and  operations  upon  the  kidney  itself,  and  other  matters  as  well,  rendered  neces- 
sary a  thon  lugh  revision  of  the  work  published  some  years  ago  as  the  joint  production  of  Drs. 
Van  Buren  and  Keyes.  Much  of  the  work  lias  been  rewritten  entirely.  There  is  a  large 
amount  of  entirely  new  matter  presented  in  tlis  volume,  to  make  room  for  which  the  reports 
of  cases  given  in  the  former  work  are  all  omitted  in  this.  The  work  in  its  present  form 
stands  fairly  abreast  of  the  latest  advances  in  genito-urinary  surgery.  Dr.  Keyes  says  of 
the  book  that  it  is  an  honest  exhibit  of  his  views  upon  all  the  subjects  considered,  and,  in  view 
of  his  wide  experience  and  unquestioned  skill,  we  commend  his  book  to  the  notice  and  study 
of  all  who  work  in  this  field."— <b'<.  Louis  Courier  of  Mtdicine. 

"  We  do  not  know  of  any  one  work  in  the  English  language,  devoted  to  diseases,  etc.,  of 
the  genito-urinary  organs,  including  the  venereal  diseases,  that  is  so  well  adapted  to  the  wants 
of  the  ireneral  practitioner.  To  the  specialist  this  book  is  invaluable." — Virginia  Medical 
Monthlj. 

"  This  handsome  volume  is  not  merely  a  new  edition  of  the  well-known  work  of  Van  Buren 
and  Keyes,  but  a  complete  revision  of  that  text-book.  The  original  plan  of  the  older  work 
has  been  retained,  and  its  scope  remains  the  same  ;  but  it  has  been  entirely  recast,  and  in  a 
large  measure  rewritten.  This  course  has  lieen  made  necessary  by  the  vast  ]irogress  which 
has  marked  the  history  of  surgery  during  the  last  ten  years,  especially  in  tlie  field  of  thera- 
peutics and  operative  procedures.  To  bring  the  book  up  abreast  of  tlie  times  upon  the  new 
device  of  litholapaxy,  suprapubic  cvstotomy,  the  modern  surgery  of  the  kidney,  the  treat- 
ment now  followed  "in  diseases  of  the  tunica  vaginalis,  and  the  many  minor  changes  which 
find  expression  in  the  use  of  new  agents.  Dr.  Keyes  was  compelled  to  omit  many  things,  to 
add  considerable  new  matter,  and  largely  to  modify  much  of  the  reniainder.  Some  chapters 
are  entirely  new,  and  in  order  to  make  room  for  desired  additions  all  the  cases  have  been 
dropped.  As  it  now  stands,  it  is  a  treatise  which  may  safely  be  consulted,  an  J  wliich  fairly 
and  freelv  speaks  of  the  most  modern  methods.  Dr.  Keyes  is  enthusiastic  in  liis  commenda 
tions  of  litholapaxy.  and  cordially  indorses  the  high  operation  for  stone,  while  be  decides 
that  the  time-honored  and  brilliant  methods  of  reaching  tljc  bladder  through  the  perinajum 
are  only  applicable  in  the  cases  of  male  children  with  stones  of  moderate  size.  Dr.  Keyes 
says  the  book  '  is  an  lioncst  exhibit  of  my  views  upon  all  the  subjects  considered ' ;  andas  ni.s 
experience  has  been  lar^e,  and  his  skill" and  prudence  are  undisputed,  we  have  no  hesitation 
in  sayinir  there  is  no  one  in  this  country  whose  judgment  is  more  worthy  of  confidence,  or 
whose  directions  may  be  more  safely  followed." — American  Journal  of  the  Medical  Sciences. 


D.   APPLETON    AND    COMPANY,  NEW   YORK 


A  TEEATISE 

ON   DISEASES   OE   THE 

RECTUM,  ANUS,  and 

SIGMOID  ELEXUEE. 

Bv  JOSEPH  M.  MATHEWS,  M.  D., 

OF    LOUISVILLE,    KY., 

Professor  of  the  Principles  and  Practice  of  Surgery,  and  Clinical  LscTrRER 

ON  Diseases  OF  the  Rectum,  in  the  Kentuckf 

School  of  Medicine,  etc. 

With  Six  Chromolithographs  and  iiumerons   Illustrations  in  the  Text. 
SECOND  EDITION,   REVISED. 

8vo,  537  pages.     Cloth  binding,  $5.00. 


SOLD    ONLY  BY  SUBSCRIPTION. 


''  The  author  has  placed  before  the  profession  the  fruits  of  fifteen  years'  experience  as  a 
rectal  specialist.  ...  A  careful  perusal  of  Mathews's  work  can  not  fail  to  give  the  practi- 
tioner all  the  knowledire  that  is  desirable  to  successfully  diagnosticate  and  treat  any  case  of 
rectal  disease  that  may  come  before  him,  if  he  possesses  a  mi'>dicum  of  the  dexterity  that  an 
ordinary  surgeon  should  have.  .  .  .  The  book  is  rich  in  clinical  material,  and,  in  the  writer's 
opinion,  is  the  best  work  on  this  specialty  yet  published.  Tlie  publishers  have  done  their 
work  well,  the  six  chromolithographs  being  artistic." — Chicago  Medical  Eecordei: 

".  .  .  The  work  is  a  most  practical  and  classical  presentation  of  the  vast  and  varied 
experience  of  a  painstaking  observer  and  worker.  The  specialist  will  buy  it  and  read  it, 
otherwise  he  would  not  be  progressive.  The  general  practitioners,  above  all,  sliould  procure 
and  read  this  book,  tor  the  reason  that  it  will  at  least  assist  them  in  making  a  correct 
diagnosis;  and.  if  they  care  to  treat  these  diseases,  it  gives  tliem  all  that  is  newest  and 
best." — Medical  Mirror. 

"  This  book  we  think  is  decidedly  original  in  many  of  its  features.  The  author  has  not 
taken  other  men's  opinions  as  his  guide,  for  the  reason  that  in  his  fifteen  years'  experience 
as  a  rectal  specialist  he  has  learned  '  that  many  things  that  are  taught  are  not  true,  and  that 
many  true  things  have  not  been  taught.'  He  has  therefore  accepted  as  truths  only  those  things 
which  could  be  substantiated  by  facts,  and  has  here  recorded' them.  Several  chapters  new 
to  books  on  this  subject  have  been  introiluced  by  him,  among  which  will  be  found  the  follow- 
ing :  Disease  in  the  Sigmoid  Flexure,  the  Hvsterical  or  Nervous  Eeetum,  Anatomy  of  the 
Rectum  in  Relation  to  Kellexes,  Antiseptics  in  kectal  Surgery,  and  a  New  Operation  for  Fistula 
inAuo.  .  .  .  Illustrated  with  six  excellent  colored  plates  and  numerous  cuts;  clearly  printed 
with  large  type,  and  nicely  bound,  it  presents  a  most  attractive  appearance.  We  do  not 
know  of  any  work  on  the  subject  which  more  thoroughly  meets  our  approval." — Memphit 
Medical  Monthly. 

D.    APPLETON    AND    COMPANY,  NEW  YORK. 


A  TREATISE  ON  THE 
DISEASES   OF  WOMEN. 

By   ALEXANDER  J.    C.    SKENE,  M.  D., 

PROFESSOR    OF    GYN^COLOUY     IN    TUK    LONG     ISLAND   COLLE(iE     HOSPITAL,    BROOKLYN,    N.     If.  ;     FOR- 
MERLY   PROPESaOR    OP    aYNvECOLOGY    IN    THE    NEW    YORK    I'OST-GRADUATE    MEDICAL 
SCHOOL    AND    HOSPITAL,     ETC. 


Third  Edition,  revised  and  enlarged.     8vo,  991  pages.     With  290  Fine 

Wood   Engravings,  and  Nine   Chromolithographs,  prepared 

especially  for  this  work. 


rp, 


SOLD   ONLY  BY  SUBSCRIPTION. 

IHIS  attractive  work  is  the  outcome  and  rt'i)resents  the  experience  of  a  long  and 
active  professional  lile,  the  greater  part  of  which  has  been  .spent  in  the  treat- 
ment of  the  diseases  of  women.  It  is  especially  adapted  to  meet  the  wants 
of  the  general  practitioner,  l)y  enabling  him  to  recognize  this  class  of  diseases  as 
he  meets  them  in  every-day  [n-actice  and  to  treat  them  successfully. 

The  arrangement  of  subjects  is  such  that  they  are  discussed  in  their  natural 
order,  and  thus  are  more  easily  comprehended  and  remembered  by  the  student. 

Methods  of  operation  have  been  much  simplified  by  the  author  in  his  practice, 
and  it  has  been  his  endeavor  to  so  describe  the  operative  procedures  adopted  by 
him,  even  to  their  minutest  details,  as  to  make  his  treatise  a  practical  guide  to  the 
gyiuecologist. 

While  attention  has  been  given  to  the  surgical  treatment  of  the  diseases  of 
women,  and  many  of  the  operations  so  simplified  as  to  bring  them  within  the 
capabilities  of  the  general  surgeon,  due  regai-d  has  also  been  paid  to  the  medical 
management  of  this  class  of  diseases. 

Although  all  the  subjects  which  are  discussed  in  the  various  text-books  on 
gynecology  have  been  treated  by  the  author,  it  has  been  a  prominent  feature  in 
his  plan  to  con.sider  also  those  which  are  but  incidentally,  or  not  at  all,  mentioned 
in  the  text-books  hitherto  published,  and  yet  which  are  constantly  presenting 
themselves  to  the  practitioner  for  diagnosis  and  treatment. 

"In  theprefficp  of  th(.  lirnt  edition  of  this  worVc  the  aiitlior  slati's  :  '  Thii^  work  was  written  for 
the  uurposeof  bnu"iii"  loKellier  the  fully  maturca  and  eHscnIiiil  facts  in  the  science  and  art  of 
evii'ecolo<'v  so  amin.'ed  as  lo  inert  the  requirements  of  the  student  of  medicine,  and  be  convenient 
to  the  practitioner  for  reference.'  The  demand  for  a  second  edition  lias  demonstrated  how  fully 
this  Durpose  has  lieen  accomplished.  The  reader  can  not  fail  to  commend  the  conBeryatisin  and 
honesty  Of  the  author's  opinions,  and  the  care  with  which  tlie  material  has  lieen  collec  ed  and 
arraiK^ed.  The  second  edition  contains  new  chapters  on  Kctopie  (Jestation,  Diseases  and  Injuries 
of  the  Ureters,  and  Vesical  Hernia.  The  first  of  these  subjects  receives  in  this  edition  a  careful 
exposition,  the  want  of  which  was  amonji  the  few  defects  of  the  former  edition.  The  author  & 
work  in  the  positional  disorders  of  the  uterus  and  laceration  of  the  penuicum  stands  pre-eminent 
anion"  the  contrii)iit  ions  to  this  subject.  His  disciiBsion  of  the  use  of  pessarns  throws  much  light  upon 
a  subject  which  has  sulTere.l  from  the  want  of  caretul  treatment,  hoth  i,io  and  mn.  The  publishers 
deserve  great  credit  for  the  ilhistrati(ms  and  general  style  of  the  work."'     Medu-al  News. 

"We  have  very  little  to  add  to  what  we  said  of  it  on  its  first  apiiearance,  and  we  still  regard  it  as 
one  of  the  few  foremost  books  in  this  department  in  the  Kiiglish  language.  1  he  addition  of 
chapters  on  Diseases  and  Injuries  of  the  Ureters,  and  on  Kctopie  (icstat^ion  make  it  more  complete. 
Too  much  praise  can  not  be' given  to  the  illustrations,  which  are  models  of  clearness,  and,  as  is  not 
always  the  case,  show  what  is  meant."— j5o«to/i  Medical  aiut  Surgical  Jonrnxa. 


I).  APPLETON    AND   COMPANY,  NEW  YORK. 


♦' 


^^OLUMBIA  UNIVERSITY  I  IHRARir 


1900 


